Medical emergencies on home turf are distressing enough, but language and cultural differences compound medical problem away from home. Even so, appropriate and optimal medical care is often easier, quicker and cheaper in a foreign country than at home.
“The bathroom floor of a Cuban hotel is a cold and hard place to spend the night. I know. I woke up on one with my face on a marble floor soaked by my own cold congealed blood. My nose was full of blood clots. It was a mess,” says Norbert Raacke, a cultural connoisseur and retired museum librarian, known as “Tippy.”
Tippy was two days into what the State Department billed as an educational exchange tour to Cuba. He had joined others from across the United States in the Miami airport for a charted flight to Havana. The small group’s jam-packed itinerary included walking tours, grub stops at local eateries, meeting contemporary Cuban artists in their studios and museum explorations. The weather was just like New Orleans’ – hot and humid.
“I remember getting up to go to the bathroom. I must have fainted on the toilet, but don’t remember much else until I woke in that puddle of blood. One thing for certain – I wasn’t drunk.”
He wiped off dried blood with a wet towel and decided to go back to bed. It was the middle of the night and he knew the American tour leader was staying miles away with a Cuban family. Night turned to dawn and Tippy was feeling a bit weak as he showered and dressed for breakfast. The bloodied bathroom looked like the site of a voodoo chicken-killing ritual gone astray. He left a generous tip for the Hotel Telegrafo chambermaid.
“He told me he passed out, came to and then passed out again. I was afraid he might have had a TIA [Transient Ischemic Attack or ‘mini-stroke’],” says Mary Willis, a nurse and patient relations administrator on the tour from California. At breakfast the tour leader was still missing in action, but Willis asked the Cuban guide assigned to the group for directions to an emergency room. Nelson, our knowledgeable guide and “former” Cuban intelligence agent, advised against going to a hospital and walked Tippy across the street to a nearby larger hotel where there was supposedly a physician in residence.
They walked through the Hotel Park Central’s expansive lobby and climbed the center stairs to the mezzanine. Nestled next to the Internet room with pay-as-you-go computers was a mezzanine office converted into a first aid station. They knocked and a voice responded “uno momento, please.” Tippy heard some bustling and water running behind the closed door.
After about four or five minutes, he was ushered into the first-aid station. Tippy learned that there was no full-time physician, but moonlighting nurses manned the station on a 24-hour basis. Nurse Munoz asked him to sit on a well-worn couch as she began taking his medical history in halting English until Tippy answered in his fluent Spanish.
The nurse sat at a large desk holding a stethoscope and a blood pressure cuff. A curtain surrounded a small examination area with visible tongue depressors, bandage scissors and a battery-powered otoscope. There was a grab-and-run emergency kit with intubation equipment but no defibrillator was nearby. The presence of multiple female shoes in the bathroom suggested that the on-call nurse slept nights on the well-worn couch in the main room, explaining the initial early-morning wait as she gathered herself together. Tippy rolled up his sleeve for a blood pressure and pulse check. His pulse was normal, but his blood pressure was low for him, at 110/70.
Fainting on the toilet, known medically as bathroom syncope, can have many causes. It is a well-known medical problem often involving a physiologic phenomenon known as vasovagal syncope. Straining on a toilet causes the vagal nerve to discharge signals causing the pulse to slow, a normal reflex that usually causes no problems.
Persons with certain altered physiologic states and heart conditions are more susceptible to the fall in pulse. Tippy was on antihypertensive medication including a diuretic that increased fluid loss. In his own words, he had “sweated like a hog waiting for slaughter” during the long walking tour the day before. In retrospect, excess exercise and activity in the hot Cuban sun, combined with a less-than-usual water intake, on top of his antihypertensive medications, caused him to faint. The nurse assured him that she had seen this many times before.
Nurse Munoz told Tippy most folks who knock on her door have diarrhea. She kept a good supply of a Lomotil-like drugs to dispense. Other common visitor problems were respiratory tract infections, leg cramps and twisted ankles. She also knew how to cut red tape if a guest needed more care than she could provide. She and the other moonlighting nurses all worked at a large municipal hospital and they had numbers to call if physicians or hospital referrals were needed.
The nurse charged Tippy 10 pesos for the checkup. She also told him to come back for a daily blood pressure check “gratis.” They became close friends over the next five days. Tippy paid no more, but he returned daily with gifts including cosmetics and a bottle of 300 aspirin he had thoughtfully packed for the trip after hearing that the Cubans chronically struggled with common medication shortages. Nurse Munoz thanked him profusely, as the clinic’s own aspirin supply was down to a mere dozen or so tablets.
In this situation, Tippy was far better served by fainting in Cuba than at home. If a person in New Orleans had shown up at a local emergency room with his story of syncope and bleeding from the nose, the typical minimum workup would have been blood tests, an EKG and a CT scan of the head. What cost Tippy the equivalent of about $9 in Cuba would easily have morphed into charges of over $2,000 in a New Orleans emergency room. The voiced rationale for the excess expensive tests is “defensive medicine;” the more likely reasons are insecure hospital-employed emergency room physicians knowing that the folks in the big office are watching what they put on the books.
“If you go to Cuba, take over-the-counter medications and cosmetics for gifts,” advises Tippy. “Before I left I heard that the Cubans needed pencils and pens. Everyone in our group was carrying pens and pencils to give away, but I had checked with a Cuban friend in New Orleans before leaving. He said take a suitcase of cosmetics. That is what the Cuban women really want. I ate lunch one day at an outdoor cafe on a green square across from an elementary school in Old Havana. At least six different groups of tourists came by passing out pencils to the students. I conversed with their teacher in Spanish, a nice young lad about 28 years old. He told me they had more pencils than they knew what to do with but continued to take them and give thanks so not to appear ungrateful.”
Medical prep for travel
Like at home, the majority of medical problems experienced by tourists abroad are simple and rarely totally disrupt a planned vacation. Common vacation nuisances include sunburn, diarrhea, chapped lips, blisters, simple sprains and insect bites.
The Centers for Disease Control recommends learning about your destination in advance and packing some basic medications and supplies. Some of their advice is best left on the website. For example, most travelers I know don’t “register with the U.S. embassy” on arrival to their destination.
Medical problems are a distraction for the afflicted traveller and their companions alike, so avoid health and safety risks. Use sunscreen and insect repellents as needed. Be careful about food and water. The most common causes of serious injuries and death for American tourists abroad are vehicular crashes and drowning, not exotic tropical diseases.
All travelers abroad should have travel health and/or evacuation insurance. Even so, persons with minor medical problems are usually better served by asking their hotel staff for nearby resources than by calling an international help line number. Save the insurance coverage for the big stuff unless you enjoy the trials and tribulations of travel to an often-distant clinic and then extracting a reimbursement from a travel insurance company.