Imagine the worst pain you can think of. Imagine it strikes you randomly, without warning. My husband, Steve, gets kidney stones. Some people do. Since we married in 2007, every so often he will have a day or so of bad pain, go to bed with a hydrocodone, and finally pass a pinhead-sized piece of gravel. This usually happens no more than two or three times a year. So, when he told me one Friday morning, after we’d been here about seven weeks, that he was passing a stone, I kissed him sympathetically on the forehead and said I’d cancel our plans to go out on the weekend. That night he was restless despite the narcotic, and the next morning he said, “This is really bad,” which is what he usually says when he’s getting ready to pass one, so I went and had my nails done. Saturday night came and went, with Steve getting little sleep and visiting the bathroom every hour or so. I was getting little sleep myself, so around 2:00 a.m., I finally sent him out to sleep on the sofa. I got six full hours of sleep, and when I woke up at 8:00, he was writhing on the couch, holding his belly. He mentioned he’d not had a bowel movement in 24 hours (possibly due to all the hydrocodone) and asked me, “Will you please go to the pharmacy and get me a laxative?”
I looked at him, gray and doubled over, and said, “No. I’m taking you to the hospital.”
Now, let me interject: people who hear you’re moving to a foreign country, especially one considered part of the developing world, fall into two camps: the “Oh, wow! Cool!” camp, and the “Are you sure that’s a good idea?” camp. In the latter camp, the naysayers, one of the most common questions, asked with a furrowed brow, is, “What if you get sick? Isn’t the medical care there kind of primitive?” People in the US have all kinds of fear connotations around medical care. I learned that fact working as a chiropractor for 28 years, acting not only as a healer, but as a lightning rod for all the anxiety, fear, and anger surrounding the issue in my native land. I could (and may, very soon) write a book about those emotions and the choices people make while under their influence. I did research healthcare before moving here, and part of the reason we chose Cuenca was because its medical facilities were reputed to be quite good. Yet, I didn’t expect to put faith in them quite so soon!
My Spanish is intermediate at best, and Steve speaks almost no Spanish. We bought US-based traveler’s health insurance before we came, but we used to see patients with those international policies at my old chiropractic office, and we never managed to get paid by them; we generally had the patients pay up front.
But, he needed help. That was plain. We hailed a taxi because Steve couldn’t walk the two blocks to the private hospital nearby, “Monte Sinaí, emergencia por favor,” and we were off.
We walked into the entrance of Monte Sinaí at 8:45 on a Sunday morning, and the waiting area was deserted. There were two rows of sturdy plastic chairs and a vacant reception booth, set off by a blood-stained fleece baby blanket (the pathos!), stuffed in a corner on the floor. “Hola!” I called, venturing further into the department, “Mi esposo está infermo…” (Hello! My husband is ill…) Two young women in colored scrub uniforms, seated at a nursing station, looked up, and one of them hustled around the desk and took Steve’s arm. Within moments, he was recumbent on a rolling gurney in a curtained emergency bay, and I was filling the nurse in on his history as she took his temperature, pulse, and blood pressure. “El tiene calculos de riñon,” (He has kidney stones) I told her, and managed to answer some questions about his general health, his normal blood pressure (a little high, but not normally that high!), and so on. I showed them a copy of his passport, filled in our address, phones, and email, and within five minutes, the ER doctor was there, and within half an hour he was wheeled back into radiology for a CT scan.
Only at that point did anyone speak to me about money. I gave them the information about the travel health policy, and unsurprisingly they could not find it in their computer system. “Yo puedo pagar con tarjeta de credito,” (I can pay with a credit card) I said, and that was that.
Steve was scarcely back from radiology, and I was standing by his side, when the ER doctor walked by with the CT images in her hand. I quickly shuffled up behind her as she put them on the viewbox, and she put a hand on my arm while we viewed them together. Less than two hours after walking in the door, we had a diagnosis: a kidney stone, a big one (12 mm), lodged at the rim of his pelvis in his left ureter, where the urine drains from the kidney into the bladder. The kidney was blown up like a balloon in the center, but the actual working part of the kidney looked normal, insofar as a CT scan would show.
“Yo voy a llamar el urólogo,” (I’m going to call the urologist) the ER doctor said. A few minutes later, she poked her head through the curtains and said, “El viene en quince minutos.” (He’s coming in 15 minutes.) A specialist was on his way. On a Sunday.
It was all of 20 minutes later that Dr. Maldonado arrived. He had done a rotation at Jackson Memorial in Miami and his English was quite good, so he was able to explain the procedure so that both Steve and I could clearly understand it. “Did you eat today? No? Good. We need to do surgery,” he said.
A moment’s panic. Maybe the naysayers were right! I immediately thought of the old-fashioned surgical way of extracting kidney stones, a gruesome procedure which used to involve cutting the pelvic floor and dissecting along the ureter until reaching the stone. “Surgery?” I squeaked, feeling a little remorseful at bringing Steve here.
“Laser surgery with an endoscope,” clarified Dr. Maldonado. I laughed inside. Of course!
I watched the nurses prep him and place the IV. Everything was done with clean gloved hands, antiseptic, clean technique, and care. They were actually much more careful and conscientious than many medical facilities I’ve visited in the US. Less than 2 and ½ hours after we arrived, Steve was wheeled into the surgical suite.
I sat in a chair in the hall. The hospital caf eteria was closed since it was Sunday, and the cappuccino machine could have been better, but everyone who passed by nodded and smiled, “Buenos días,” even the floor sweeper. I thought about how remarkably efficient and competent everyone was. I remembered a conversation we’d had with a young woman from one of our Spanish conversation classes. She was a German, a recent medical graduate doing a rotation at one of the free public hospitals. “I certainly hope you have health insurance,” she told us. “You do NOT want to go to the free hospitals. I have never seen such things! Everyone will be scrubbed for a procedure and they will discover they are missing something needed and decide on the spot that they are going to do a completely different surgery. They are short of everything and the care is frightening.”
We assured her we had purchased insurance, and I added, “The price of the insurance was very reasonable. By US standards.” And that was true. Five months of coverage for the two of us cost less than one month of coverage for me alone, with a huge deductible, when I had a policy through my small business for me and my employees. I recalled that there are three levels of healthcare in Ecuador. The first is free, public healthcare, available to all without charge (and as noted above, you get what you pay for). The intermediate tier is the IESS, sort of analogous to Medicare in that all retirees are automatically covered, but anyone can pay a monthly premium (currently around $80, but due to increase soon) and get coverage; many expatriates enroll in this when they get their residency visa, and the comments I’ve heard are that the care is good, the copayments are reasonable, but there are long waits for specialists and some types of procedures and lots of line-waiting and red tape. The hospital where I was sitting was a third-tier, private hospital. I’d heard, but not quite believed, that the care there was comparable to anything you’d get back home, and the costs were reasonable.
Within the hour, Dr. Maldonado emerged, told me all went well, and sent me downstairs to wait for Steve to come out of recovery.
Steve and I spent the rest of the afternoon in a private room, watching saline drip into his arm and urine drip into a container through a catheter. His family and my kids were messaging their concern and love across the ocean from another continent. The nurses came by to check every now and then, and my Spanish utterly failed me when it came to asking, “When can the catheter come out so he can go home?” But finally Dr. Maldonado came by. He presented us with the kidney stone itself, “It’s a big one…and this is just what was left after I pulverized it with the laser!” He instructed the nurses to take the catheter out, and told us that as soon as Steve urinated normally, we could leave. He explained there was also an internal catheter in the ureter, to keep it from swelling shut, and that Steve would need to return in two weeks to have the internal catheter removed.
In the meantime, Dr. Maldonado told us to be at his office next door Tuesday at 4:00 p.m. for a follow-up. He gave us his personal cell phone number, shook Steve’s hand, kissed my cheek, and left.
The nurses came by with multiple cups of water, so it wasn’t long until Steve was able to do what most of us take for granted, but in the meantime they handed me a slip of paper and sent me up to the billing office to settle the bill. The billing office for this seven-story hospital was the size of the billing office in my chiropractic clinic in Florida. Dr. Maldonado was just finishing up with the paperwork as I walked in, and it took a few minutes for the clerk to get the total. She asked me if I wanted to make payments, but I said no, I’d pay in
full by credit card. She presented me with the bill: $2,365.06. I saw a line item for the ER, for medications…radiology…anesthesia…Dr. Maldonado’s $900 fee. “Está todo?” (Is this everything?) I asked. “Voy a recibir una cuenta del anesthesiologo o asÍ?” (Am I going to get a bill from the anesthesiogist or anything?)
She looked at me kind of strangely, “No, está todo, señora.” I later learned this even included the follow-up visits at Dr. Maldonado’s office. I did a silent money dance inside my head. That day of care would have dragged on for three or four days, and cost ten times as much, in Tallahassee. A dozen or more shifts of workers would have had their hands involved, and the chances he’d come home with an infection or permanent kidney damage due to the delay would have been much higher.
We left the hospital at 7:20, less than 11 hours after arriving, and Steve was sleeping peacefully in our bed by 9:00 p.m.
At the follow-up visit, Dr. Maldonado was an hour late. He had no receptionist; he just opened the door to his little office and ushered us in. He gave us a lecture about the causes and prevention of kidney stones, most of which we knew, and told us to come back in two weeks to check in before the catheter removal procedure. Steve had a bad couple of weeks; apparently having an internal catheter is not the most comfortable thing in the world.
At the two-week appointment, Dr. Maldonado was 45 minutes late. It’s true what they say about the Latin sense of time, so we calmly waited in the hall, met with him, and set up a time three days later for him to take the catheter out. Steve strongly preferred anesthesia for this, and Dr. Maldonado laughed, “I don’t blame you, I would want the same thing too.”
The admission for the removal was, interestingly, done through the Emergency Room as well. Things were considerably more hectic at the hospital, with it being a weekday. Tiny little nurses (most Ecuadorians are tiny) sprinted up and down the hall like colorful comets. Steve got forgotten a couple of times when true emergencies distracted everyone, and he lay there in his little paper gown for a long time. I had forgotten what it was like to be in a curtained cubicle instead of a private room while someone was getting stitched up right next to you, complete with whimpers and bits of bloody gauze hitting the floor right at your feet on the other side of the curtain. They are not as concerned with privacy rules and regulations here, which can be a good thing when common sense prevails (but can be a little worrisome in financial settings, but that’s another post).
It was a couple of hours until they took him back, and then a few more hours until he was released. The total bill this time? $432.00. <RANT>: How can a fully private hospital in Ecuador, where the average person’s total income is not much more than the average US taxpayer pays in taxes, afford to provide excellent (excellent!) care for a tenth the cost? I know the answer to this question: the regulatory maw of the US HCFA, and OIG, in hand-in-glove collaboration with the AMA, ACHC, and the alphabet soup of ever-proliferating agencies, swallows up the time, money and energy of everyone who comes in contact with it, so that administrators and the bureaucrats they placate often make more than the doctors who actually perform the treatments, all without getting their feet sore or their hands dirty. The insanity of the rules mean doctors cannot legally discount their fees, only increase them. No wonder US doctors are looking for the exit doors! </END RANT>.
Steve had another follow-up a few days later, and Dr. Maldonado wants to do a metabolic workup just to make sure there is no unusual reason for him to have these stones.
This will happen in a few more weeks, but for now all is well. We have walked all around town, shopped at the mercados, and Steve has planted hibiscus and set out hummingbird feeders on the terrace.
It’s funny how much more beautiful the world looks after the illness of someone you love has struck fear into your heart. After an experience like that, it’s easier to remember Ecuador’s motto, Ama la vida.