I have been an emergency physician for over three decades. I am partially blind but have remained active doing medical mission work overseas. In December 2018, I went on a medical mission trip with another emergency physician to Thailand. Afterward, I extended my travel to explore more of Asia and make my way to Cambodia. I had heard of a charitable hospital called Sonja Kill Memorial Hospital in Kampot, Cambodia, so I wanted to visit them to see if I could be of service. However, my plans were suddenly interrupted when passing through Laos on my way there.
Explore This IssueACEP Now: Vol 40 – No 02 – February 2021
I was walking along a highway in Laos. It was dark. A semi-trailer swerved off the road and struck me. I suffered a brief loss of consciousness. I woke up in a rice paddy on my back, quadriplegic, and starving for air. Immediately, I concluded that I had severed my spinal cord at a high level. I was ready to die as I stared at the beautiful moon and stars. What actually had happened was that I fractured my C4 and C5 and my spinal cord was in “shock.” I passed out from asphyxia.
When I regained consciousness, I knew I was in critical condition. I was in severe pain and desperately struggling to breathe. I took a few moments to do a secondary survey on myself. I had an open fracture of my left lower extremity, broken neck (which turned out to be teardrop fractures at C4 and C5), several rib fractures, a hemopneumothorax, an exploded right shoulder, and paralyzed right upper extremity. I could taste blood, but other than facial abrasions and swelling, my cranium seemed intact. I had abdomen pain, but on exam, I was soft and not peritoneal. I was still cognitively intact. I realized if I were to have a chance of survival, I would need help. But nobody was there.
It took what seemed like forever to crawl back to the highway. The passersby would not stop. After about 20 minutes lying next to the highway, in plain sight, I had no option but to use myself to try to stop traffic. I crawled into oncoming traffic, hoping the drivers would see me and stop. It worked. I was scooped up and thrown in a pickup bed. I bounced my way to the nearest hospital.
The facility was not well-equipped but managed to give me the large needle I requested. I knew I at least had a pneumothorax, as subcutaneous air was accumulating around my chest and neck. I wanted to be prepared to perform an auto-thoracostomy if tension built up.
The hospital workers put me in the back of an old van, and I bounced around for four hours to the next hospital. Four hours of hell. I thought of late Sen. John McCain’s experience in a rice paddy.
After arriving, the hospital called my family, who called my insurance company, who misread my coverage and told them I was not covered in the country of Laos. Without insurance and with little cash on hand, I did not get treatment. They advised me that I needed to go to another hospital. I refused.
I was starting to become delirious, so they put me in a hospital ward. After 16 hours, the doctor returned to check on me. My oxygen saturations were in the 70s. I was in no condition to refuse any course of action. I was sent to Thailand, where on arrival to the next hospital, a chest tube was placed. They attended to my open fracture but not until my friend from Chang Mai flew to my rescue with cash in hand. Later, I was sent to the fourth and final hospital for definitive care.
Because of the extensive buildup of subcutaneous air, further surgery was delayed four more days. In the meantime, I was put in the ICU. I will never know if that delay contributed to my permanent paralysis.
The surgeon fixed my shoulder “the best they could.” By then, the insurance company confirmed that, in fact, I was covered for care, even in Laos. It was only after I recovered from anesthesia that I noticed my neck pain. Prior to my shoulder repair, the neck pain had been masked by my shoulder pain—the ultimate distracting injury. The team found the teardrop fractures. I told them I would deal with that once back home. I refused transfer to yet another hospital, this time in Bangkok. I figured that if my previous transports and intubations had not killed me, my neck was stable enough.
I spent a month in the hospital and flew home recumbent. I still suffer neck pain and shoulder paralysis, but I am thankful to be alive. The final bill, all told, came out to around $40,000, a fraction of what it would cost in the United States.
This is not just about me telling my unusual story. I want you to learn and educate others about the dangers that exist when emergent treatment is needed and you are far from home. As more and more people adventure to remote destinations, we need to be aware of the risks for ourselves and our friends and family. But it is also a call to action. We must assist in ongoing international efforts to help countries establish EMS programs and to obtain better emergency equipment and training.
Of course, I emphasize to all travelers to do what you can to avoid risky behaviors. In the event of an emergency, we or our representatives must make it clear to insurance providers that their immediate action is necessary. Without proper confirmation of coverage, lifesaving treatment may be withheld. You don’t want to die because someone said the wrong thing on the phone. I suspect that travelers and insurers do not realize that what happened to me could happen to others. In many wealthier countries, patients get lifesaving measures first and insurance is discussed later.
Since my accident, I’ve seen that I’m not the only person at risk. I made it to back to Sonja Kill Memorial Hospital in Cambodia to teach this year. While there, I witnessed a young tourist get hit by a van as he pulled onto the highway on his motorbike. Initially unconscious like I had been, he woke up with altered mental status and had severe facial fractures. We were able to get him to our emergency department. We did not have a CT scanner, and he needed be transferred to Phnom Penh. Getting his insurance confirmation took several hours. All the while, he lay in our emergency department. What if he had an emergent need for neurosurgery?
Before you travel abroad, make sure you know where your coverage covers you. If you need to add coverage, do it. If you truly are covered in remote locations, carry documentation to that effect. Additionally, it never hurts to carry some extra cash, avoid traveling alone, and keep an app on your phone for translations. Make sure copies of your insurance papers and emergency contact numbers are in your wallet, luggage, or backpack. Make these things easy to find. You may not be conscious and able to assist when that information is needed.
All that said, please do not let these stories deter you from traveling to wonderful places or providing medical care in places that need someone with your skills. Just be aware of this danger and prepare for any eventuality that may occur. I have been a family physician and emergency physician for more than three decades. But, by far, the greatest reward I have found is from volunteering my services to those much less fortunate than myself. I wouldn’t give that up for anything.
Dr. Wernecke is an emergency physician in Hot Springs, Arkansas. He also serves the medical missions CMO-COB Christian Mission to the Orient in Chiang Mai, Thailand, and Sonja Kill Memorial Hospital in Kampot, Cambodia administered by HOPE Worldwide.