It all started out as a trip of a lifetime, planned for many years, and implemented within the past 18 months. We specifically chose our room to have the best views of the glaciers during the last 2 days of the cruise. Finally, it was "C" day (cruise day) and, I must say, I did not expect to experience health care on a cruise line. It was not necessarily a bad experience, but it was interesting to compare-and educational.
It was right before those last 2 days that my husband started getting ill. At first, it was fevers (although I had no thermometer, his skin was hot), intense coughing, nausea, and vomiting, and a definite similarity to a kidney stone episode 6 months earlier; two things going on, perhaps? I waited it out until, in the wee hours of the morning, this unusual conversation alerted me that it was time to wake up the medical staff:
Husband: They have an excellent menu here.
Wife: What is on it?
Husband: Seal Blubber.
Wife: What else is on the menu?
Husband: Just seal blubber. An excellent menu.
It was like a small emergency department (ED) with several well-equipped rooms. There was a waiting room (which could hold probably a dozen people) and probably another room with larger diagnostic equipment. As typical, a registered nurse (RN) took vitals and recent medical history. Blood was drawn, a urinalysis was done, a bedside electrocardiogram for complaints of chest pain was done, the pulse oximeter and oxygen were placed, a nebulizer treatment was given, an influenza A/B test was obtained ... and then the physician came into the room. He asked several questions. He stated that he was taking a thorough assessment (I agreed). He then gave the RN orders for injections and, after several more questions, he again stated that he was taking a thorough assessment; I agreed-again-and stated that it seemed like two diagnoses were happening simultaneously (kidney stones and something else). We spent several hours in the ship's hospital with conservative treatment administered by the RN, when the ship physician came in to give us the hard message:
Physician: We know what is wrong with you (besides kidney stones).
Me: What?
Physician: Your husband tested positive for influenza type A.
Me: OK-that's viral, correct?
Physician: Yes. I will give him Tamiflu (Genentech, San Francisco, CA) and you will have to be quarantined.
Me: OK.
Physician (thinking I wasn't "getting it")-You will have to stay IN YOUR ROOM.
Me: OK.
Physician (thinking I STILL wasn't "getting it," when actually I was visualizing a lovely 2 days on the balcony)-You cannot leave your room!
Me: OK. So how do I pay for this care?
The talk turned to payment, insurance, the needed medical records, the "meaning of quarantine," supportive care, the next 2 days with "home" nurses coming to the cabin to check vital signs and manage the intravenous line, the "meaning of quarantine (OK!)." Then the bill, insurance papers, acetaminophen, and antinausea medication were given.
A couple of issues were very interesting when comparisons between a noncomplex ED visit on the mainland for kidney stones and this ED visit for kidney stones and influenza were made.
First, the total bill on the ship (including three RN "home" visits) came to $551.00; the "mainland" ED visit for one diagnosis was $2,183.00. The only one-to-one comparison I could make was for intravenous ketorolac: boat = $14.42 versus mainland ED = $52.00.
Second, the ship's physician did make a thorough assessment (so did the mainland ED physician). By doing so and looking at the blood work, the urinalysis, and the response to ketorolac, that kidney stones were likely-so no computed tomographic scan was done this time. The flu test was relatively inexpensive ($23.70) and, with the answers to multiple questions and the positive response to the treatments, the ship physician did not feel the need to do a huge workup or major supportive care. Just an observation ....
And, in the adage of "everything old is new again," a national public radio clip (Hamilton, 2014) discussed a Harvard neurologist who uses his eyes, ears, and brain to diagnose problems in the nervous system, rather than relying only on high-tech devices. Dr Allan Ropper (Harvard Neurologist) states that when someone develops a serious brain problem, it can be like falling down a rabbit hole and entering an "Alice in Wonderland" world, where nothing works or looks the way it used to. He and his coauthor Brian Burrell dedicated one chapter to patients with brain and nervous system symptoms, whose problems cannot be detected by any test or scan; the new book is called Reaching Down the Rabbit Hole.
It has been a long time (Vol. 14/No. 5) in 2009 since Professional Case Management had much on medical tourism. Even then (and certainly today), case managers must discharge patients to other countries. And even today, we hear of treatments being done outside of the United States (plastic surgery and orthopedic procedures) that are less costly.
In 2009, we had many questions:
1. Are traditional methods to measure quality abroad very different? Is it more stringent in the United States or elsewhere?
2. Are there standards for international case management practices? Language alone brings case management challenges.
3. Are devices safe? Are there regulatory organizations overseeing these devices elsewhere?
4. Pharmaceuticals may vary in bioequivalence between countries, as may counterfeit drugs.
5. If care is done in a foreign country, how is follow-up care accomplished? If care is done here and we send a patient back to his or her country, how do we (can we?) ensure good follow-up care?
All things being equal, was our care equal on the mainland and on the ship? This minor experience could not determine the answer. In all honesty, in a real crisis, I would want to be home. Even the generic names for medications were unfamiliar. However, the quarantine was fine and the views were lovely! (see Figure 1).
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