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Saturday, September 7, 2013

A Road Trip and A Visit to A Hospital

(Some names changes to protect identities)

Though born in a poor country I've been quite blessed with excellent medical care all my life. My Dad has been a senior doctor in India's premier hospital for the longest time and our entire family enjoyed first class treatment from the country's finest doctors. And while India's medical system shakes and heaves with overwhelming demand, but short supply of medical care, my family is fortunate to have always been bumped to the front of the queue. Consequently, a childhood cosseted with these privileges didn't quite prepare me for a first-hand experience with the struggling medical system in a different developing country, during this surf trip in Sri Lanka.

A week ago, on Aug 21, a day that is celebrated as a holiday across Sri Lanka as Poya (full moon) day, my friend Jim was the victim of a head-on collision with an errant bus while on his motorcycle. Though the accident and the injuries were extremely severe he is on the road to full recovery. He was extremely lucky. Here is the run down:

I needed to make a visa run to Colombo and figured it was time that I took a road trip, saw some new sights, and took a break from the tourist bubble that is Arugam Bay. Here was also a chance to take my motorcycle on a real ride outside of the simple beach shuttles to the nearby surf breaks. Over time I've grown to appreciate the high risk of riding on two-wheelers and dislike it as a means of pure leisure. The idea of a long and self-sufficient motorcycle ride through the beautiful landscape that is the Sri Lanka hill country appeared seductive, esp when pitted against the long and hot bumpiness of the abysmal national bus network. My friend Jess gamely offered to accompany me on the back seat, and we left Arugam Bay one afternoon making our way through scenic stops in Nuwara Eliya for some tea tourism, and Kandy for the spectacular annual Perihara festival. Jess left Kandy back for the Bay and I continued on to Colombo for collecting my visa extension stamp. On the return I had to see an eye doctor in Kandy and figured that I'd meet up with my Aussie friend Jim - 22, healthy and full of adventure. My riding through the country had been mostly uneventful, though I did go through a crash course in biking through windy mountain roads and managing the various kind of road inhabitants - cars, buses, trucks, pedestrians, dogs and cows - that require constant vigilance and quick reflexes. The riding was more tiring than I could have imagined. It quickly became a chore and I decided that I wasn't riding motorcycles again for simply for pure pleasure. Short surf commutes on mostly deserted beach roads were one thing, long rides with chaotic unruly bi-directional traffic much different. It drove home the point on why I had not gotten behind a bike in the last 14 years. 

Jess left back for Arugam early on and after a quick run to Colombo for my visa, I returned back to Kandy to join Jim for the ride back from Kandy to Arugam. Tuesday early morning after a quick breakfast of tea and biscuits, Jim and I got on the road at about 7 am towards Mahiyangana, one of the stops on the way to the coast. In about 20 minutes we were outside Kandy and were hoping to soon escape heavy traffic as we headed out away from the congested suburban highway. At different points Jim and I'd take turns being in front. The windy roads were a bit tricky but we were alert after a good night's sleep and I was enjoying the cool air and casual pace on the scenic loops. Jim was ahead of me and next to a small lorry when a public bus rounded a corner a bit too wide and spilled onto our side of the road, directly on to Jim's oncoming trajectory. Jim tried his best to swerve away but there was no time or room. The bus traveling at perhaps 60 kmph hit him head on and his bike spun out, careening wildly towards the shoulder. I had to brake and turn rapidly to avoid running over the carnage. The next thing I remember is Jim lying besides his bike, screaming in agony as he tried to extricate himself from underneath the bike. I quickly parked and dashed over. I was in utter disbelief. In the middle of the bike debris, Jim was holding his right leg that was spewing blood out of a massive open hole on the front of the thigh. His femur had broken in two and was sticking out of his leg at an acute angle. You could see through all the layers of muscle, cartilage and bone. The calf and foot were also bent at unnatural angles indicating multiple breaks through the leg. Jim was apoplectic with shock and pain that I could not begin to imagine. A crowd of onlookers had gathered pointing towards the bike which had now caught fire owing to the punctured fuel tank. We moved Jim a bit away and I started jumping wildly and yelling to call for an ambulance. Ambulance / EMT services in Sri Lanka appear primitive at best and I guessed correctly that paramedics would not be so quick to arrive and we were losing time rapidly. I had to restrain some well-meaning but misbegotten folks who wanted to load him onto a tuk tuk (3 wheeler taxi)! Fortunately a van carrying a young family stopped and swiftly agreed to take Jim to the Kandy General Hospital. Being loaded into the van back seat, without a stretcher, with a crushed leg and untrained hands is an experience that hopefully nobody I know has to endure. Suffice it to say that we got him inside and I jumped next to him cradling his back and shoulder. JIm's face was completely ashen but miraculously he stayed conscious through the 25 minute drive to the General Hospital (which I was told is the biggest in town and the best suited for handling an accident of this magnitude). He was moaning the whole time and I remember shivering a bit too in fear and shock as I tried to calm him a bit - very difficult when you are experiencing unimaginable pain, holding your own bloodied leg that has split open like overripe fruit. 

The drive felt like eternity but we finally made it to the hospital. We parked outside Emergency and I jumped out and started shouting for help. The staff hanging around outside seemed stunned like deer caught in headlights and took a few moments to spring to action. We loaded Jim onto a metal stretcher and raced inside. While I'm not a medical professional it seemed that the staff was a bit rough as they wheeled him in and got some first aid organised. They didn't seem to be nestling his body properly and the metal stretcher was hardly designed for impact or comfort. The handling coarseness seemed a constant through the stay at the hospital that followed -- another bit of culture shock coming from the West where we are a bit over-diagnosed and over-medicated and we get treated with kid gloves at hospitals and every affliction gets plenty of care and attention. Anyway more on that later. 

Fortunately Jim was the only emergency patient at the time and the entire staff at hand galvanised around him. The ER doctor took a quick look, asked a few questions about the accident and directed the nurses to start cleaning his wounds and dress them, as well as prepare antibiotic and pain killer injections. JIm's wails were vexing and I was surprised that it took some imploring to get them to rush the morphine into his system. Because of the holiday the hospital was operating on a lean schedule and it took some time for the Orthopaedist on staff to show up. She took a look at him, barked some things to the staff around the quality of the dressings - she thought the broken bone sticking out of his upper leg underneath the dressing was a splint that was too short for the length of his thigh! Brad, Semira (visiting friends from the US) and Chaminda (Jim's local buddy) showed up and I felt immediately comforted to have friends at hand. We hugged and I broke down for a moment releasing some of the shock of the accident.

The Orthopaedic ward felt like a sick bay at an army camp. We were greeted by sick patients lying on stretchers (or sometimes even the floor!) on different sides of the hallway as we wheeled Jim in. Given the depth and severity of the wounds, surgery was an immediate need. They stationed him in a corner and waited for the Orthopaedic surgeon to arrive. We were told that he had been informed and would be over shortly. The wait might have been the most distressing period in the entire saga. Jim was in sheer agony. They were stingy with the pain meds - possibly to avoid overdosing, and also on account of the local culture where some suffering is considered normal. For this country had just come out of a bloody 30 year civil war and some of the staff were sure to have helped take care of war victims. That was hardly comfort for us though as we felt that Jim was being somewhat neglected and the assurances seemed a bit phoney. We continued harassing the staff to summon the specialist and also get the surgery under way. I was very glad to have friends around who could stay by Jim as I ran around like a headless chicken. Eventually Dr Sanet, the Ortho surgeon showed up - he had been occupied in the OT (operation theatre) with another surgery - and he started examining Jim's x-rays. His demeanour radiated confidence and expertise and his soothing bedside manner cut through the roughness and (sometimes) klutziness of the staff around. We felt immediately better when Dr Sanet suggested that after examining the X-rays and Jim's condition, he was going to rush him into the OT (operation theatre) to thoroughly clean, and then close up the open abscesses. For we learnt that more than the risk of losing mobility in the injured leg, there was risk of blood infection that could lead to fairly serious complications. The operation took a few hours and in the mean time I called up Jim's folks in Perth, Australia who promised to rush over on the first available flight. 

The operation went well and Jim came out in a new set of better looking dressings. However he was still in considerable distress from the pain. They continued to ration the pain meds, to prevent addiction, but to also spread scarce resources around. The first night at the hospital was tough. I spent it by Jim's side and he would wake up every so often in pain and also in misery because he couldn't pee. If I hadn't intervened then the nurses wouldn't have put a catheter on him and he would have continued to suffer. The nurses and staff in general seemed somewhat cavalier about the suffering around. I imagine 30 years of civil war and a constant barrage of road injuries in an under-staffed hospital will do that to you. The one bit of comic relief came when a couple of Jim's drunk local buddies dropped by at the friendly hour of 2 am. Friends are not permitted out of visiting hours (and I had to plead to be allowed to stay) and these guys in their inebriated states, barraged their way into the intensive care ward. They meant well but JIm was obviously not in a condition to see them. And they weren't either! It was only when Jim whimpered in pain at an attempt for a bro-hug (!) by one of the guys, did they realise their folly and left apologetically. Whew! I almost lost my own visiting rights for a moment there. After the catheter and a round of Bethadine, Jim drifted off to sleep. Chaminda came by sometime the next morning and I went back to the house for some food and a much needed nap. Brad and Semira were very helpful in staying at the hospital while I was away and continuing to apply pressure on the staff to look after Jim. We shuddered in horror when we learnt from some visiting British nurses that one of the patients, a guy in a bed across from Jim, was going to have his leg amputated soon. And only because they didn't have enough antibiotics for him and his leg became infected with gangrene . Woah. It made us doubly anxious to see that Jim was looked after and for his parents to arrive.

After a long day of travel, Jim's parents, Bruce and Sarah, showed up later that afternoon, and after initial shock at the state of the hospital, ('something from the middle ages', being Bruce's comment). they quickly took charge. They (and Jim) were very glad to see each other and I admittedly felt relief to be able to pass on the responsibility for critical decisions. For we needed to decide whether to plan the next round of surgery, or begin operations to have Jim medi-vaced back home. After much deliberation with the head surgeon, the family decided that the risk of transport at this stage was simply too high as any delay in surgery may cause fat embolism among other complications. The second surgery was scheduled for the next morning and was long and very complicated as I understood. They passed metal wires through his thigh as well as his lower leg to splint the broken bones and do some work with the Achilles tendon as well which was completely destroyed. Bruce and Sarah's presence had made a significant difference to the situation. Not only were the best surgeons operating on Jim, the nurses and other staff were diligent and attentive as well. Trickle-down effect from the top I imagine. Coming out of the surgery, Jim was put on a morphine drip and administered Valium to help him cope with the intense post-operative trauma. Chaminda and myself helped look after Jim the second night and were relieved by Bruce who came early in the morning to take over. Another interesting bit of local culture where women are not allowed in the men's ward. Hence poor Sarah was unable to stay with her son over night.

Things got slowly but progressively better from that point. It was apparent that Jim was being given the best care that the hospital could afford. He was the only critical patient at the time and the Orthopaedic staff started looking after him quite well. Sri Lanka does have a tradition of hospitality for outsiders and that started becoming apparent through the healing process. For at times it seemed that Jim received more care than other (local) cases around. Gentle persuasions from the parents certainly didn't hurt and having family around certainly bolstered Jim's spirits. Bruce and Sarah took over and I transitioned out of the care process. Semira, Brad and I left Kandy a couple of days later assured that the parents had the situation well managed and Jim was healing under the able care of the medics. In fact Jim showed remarkable progress even surprising the doctors. Great to have a twenty-two year old's mind and body!

I decided to leave my motorcycle behind for the time being and take a taxi back to Arugam Bay. I was still under shock from the accident and didn't like the idea of riding back on the same roads. Part of me still nurses some guilt that Jim got clobbered taking 'one for the team'. I was right behind him and it could have been me instead on that hospital bed. 


Today is September 7 as I finish writing this essay. Jim's accident was almost 3 weeks ago. Just spoke to him this morning after he had his dressings changed. Always a painful experience. His return home to Australia has been fixed a week from now and I think the imminence is buoying everybody's spirits. He won't need the usurious services of the Medivac company. He'll be able to travel in a normal airplane though on a First Class seat where he can keep his injured leg in a lying position. He enjoyed hearing about the big (surf) swell in Arugam currently though his next time in the water is a good bit away. He's looking forward to a complete recovery. 

The medical system in Sri Lanka can teach a lot to Western countries, esp USA, my place of residence. Medical care in Sri Lanka is almost completely free, even for foreigners, and even for very complicated processes like JIm's multiple surgeries and convalescence. What would be hundreds and thousands of dollars in the USA costs only a fraction here. Jim's parents were asked to pay for actuals used for dressings, bed sheets, pillows and miscellany that the hospital couldn't provide themselves. Unimaginable in our medical system where health care is run like a well-oiled business and profits are calculated every step of the way. Health care should indeed be a birth right and I'm sure with a fast-growing economy and rising GDP, Sri Lanka's hospitals will in time rival the West.

I do not like being on two-wheelers. I can see the convenience and need for one in poor countries or crowded cities where parking a car is an issue. And while I have many friends who ride motorcycles for fun, it does not appeal to me at all. On a bike it's all about speed and one of the clichey but sobering signs on Indian roads comes to mind  - Speed Thrills But Kills. So quite true. There were certainly moments of pleasure riding by the lovely mountain sides and tea plantations of Sri Lanka's hill country. However it was tiring and stressful to be on high alert the entire time. Mistakes can be fatal and all too easy to make while dodging pedestrians, animals and of course the maniacal bus drivers who spare no one. I'm convinced that the whole notion of driving motorcycles around Asia as a romantic escape is a myth, a very dangerous one. Getting into an accident is far too easy and without standard EMT services and properly equipped hospitals, even simple accidents can be life-changing. Jim's collision would have had much worse consequences had we not been near a major city and if I had not been there to rush him to a hospital and all of us weren't around to cajole and bully the staff into giving him the best care possible. While developed countries can offer better driving conditions,
Jim, Chaminda and I about 5 days after the accident.
motorcycle riders always come out the worse in any road mishaps. While I saw Jim's up close and personal, I've had many other friends who have been hurt on their bikes, in the US and overseas. Brad offered the sobering reflection that the worst x-rays seen by his Dad, a very experienced Radiologist in the US, of motorcycle accident victims. 

I implore my friends and readers to avoid riding motorcycles for fun, or at least be cognizant of the risks and take all precautions if you still choose to. 

1 comment:

  1. Kush, a detailed account, and thank you, for sharing with us. It is good to know that Jim is making requisite recovery, and should be home soon for convalescing and mobilization. Yes, being young helps.
    Sri Lanka may be a poor country, but it has its health statastics comparable to the western countries, and is the best among its south asian neighbours. 30 years of ethnic strife has taken its toll on many fronts, including health services, but with the right political will and ploughing back of scarce resources now to social sectors, it will soon remove some of the blemishes that you have described.