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Wednesday, June 22, 2011

Indonesia Epilogue: The Bite Heard Around the World


I was bitten by a monkey in Indonesia.  This turned out to be an incredibly big deal once I got back to the US, but was decidedly NOT a big deal while I was still in Indonesia. In fact, it ended up being the single biggest event that took place on our three week trip.

The fun started while were still in Bali.  First, a German guy in our hotel suggested that I get rabies shots.  Since I'd heard horrible stories about rabies shots, I didn't want to do this.  Haven't you heard these horror stories of rabies shots?  That you have to get like 20 of them, and they're painful and they're in your abdomen?  So, you can imagine my reluctance at this since, and I'll have to repeat this through the whole story, the monkey did not have rabies.


How do I know the monkey didn't have rabies?  Well, this is not some random wooded area I was walking through.  This was the Ubud Sacred Monkey Forest, a known Bali tourist area.  While Americans might not know about it, there are tons of Australians that go there.  If a monkey were to test positive for rabies in the Sacred Monkey Forest, it would be a news story - at least in Australia and Indonesia.  They haven't.  In fact, no monkey has tested positive for rabies on Bali.  Ever.  That being said, though, there does happen to be a serious rabies problem with dogs in Bali.  Between November 2008 and February 2011, 119 people died from rabies on Bali, exclusively dog bites.  Five of those people were just in January and February.  Had I really given this stronger consideration (and in hindsight, certainly), I would have gotten the rabies vaccination before going to Indonesia when I had the vaccinations for Japanese Encephalitis, Hepatitis, Typhoid, etc.  I actually turned the rabies vaccine down.

I ended up seeing a doctor because if you read about what happens when you have rabies, it is scary.  I mean, this is a SCARY disease, not to be taken lightly at all.  If it wasn't too much trouble to see a doctor, I figured it was better to do so, especially because we were leaving the next day. From the CDC:

The first symptoms of rabies may be very similar to those of the flu including general weakness or discomfort, fever, or headache. These symptoms may last for days.

There may be also discomfort or a prickling or itching sensation at the site of bite, progressing within days to symptoms of cerebral dysfunction, anxiety, confusion, agitation. As the disease progresses, the person may experience delirium, abnormal behavior, hallucinations, and insomnia.

The acute period of disease typically ends after 2 to 10 days. Once clinical signs of rabies appear, the disease is nearly always fatal, and treatment is typically supportive.

Disease prevention includes administration of both passive antibody, through an injection of human immune globulin and a round of injections with rabies vaccine.

Once a person begins to exhibit signs of the disease, survival is rare. To date less than 10 documented cases of human survival from clinical rabies have been reported and only two have not had a history of pre- or postexposure prophylaxis.

The clinic in Indonesia?  Totally clean, nice, wonderful.  Exactly what I would expect of a Patient First or other Urgent Care facility in the US.  If someone has scared you about medical care in other countries, don't worry about it, at least in Bali.  I was the only patient there, and the staff consisted of a nurse and a doctor.  The doctor saw my bite, and said he'd give me a tetanus shot.  I said no, I'd had a tetanus shot, what about rabies?  He kind of shrugged and said he'd start me on the rabies vaccines.

On that day, I received two rabies vaccine shots, one in each arm.  This was designed to jump start my body into producing antibodies to fight the rabies.  He recommended against the immune globulin (which is HRIG if it comes from humans or ERIG if it comes from horses) because it's rare and expensive in Indonesia, and it's the ERIG version, which isn't as good as the HRIG.  And this was a minor bite, a Category II according to the World Health Organization, which does not require RIG, but does require vaccines.  I was then to follow up in the US, with another rabies vaccine in 7 days, and a fourth vaccine in 21 days.  That seemed acceptable to me.  I verified on the WHO site that this was fine, that the "two vaccines on the first day" thing was totally valid when the RIG shots weren't being administered.  Awesome.  I went on with my vacation.  Total cost in Indonesia for two shots, a doctors visit and a wound cleaning: $120 US.

I arrived back in the US the evening of February 12, which was a Saturday.  Monday, February 14, I started dealing with the rabies thing, since that Thursday (the 17th), I would need to get my next rabies vaccine.  First, I called our travel insurance company to put in a claim.  I filled out their paperwork and sent it back, and let them know that I would have more bills coming since my treatment was not complete.

Next, I called Passport Health, who had administered my vaccines before I left for Indonesia.  This is when I got my first taste of classic United States freak out about rabies.  Passport Health had a nurse call me back.  She wanted to find out more information, and had never heard of the "2 vaccines on the first day" thing.  She was surprised I hadn't gotten the HRIG shot, and suggested that I call my county health department to see if they had the HRIG shots in case I needed it.  She then went to check with a doctor.  I called my county's health department.  This ended up being a HUGE HUGE MISTAKE.  I left a message with the woman who was in charge of the rabies hotline or whatever, since she didn't answer.  A few minutes later, Passport Health called back and said that I wouldn't need the HRIG shot because too much time had passed since the bite (it had now been 4 days), and getting the HRIG would actually compromise my immunity at this point.  This totally jived with things I had read on the WHO and CDC websites. I made an appointment to have my third vaccine on February 17, and I thought all was good.

Then, the health department called me back. In the period of time that she'd taken to call me back, the woman at the health department had contacted the state health department, and apparently a bunch of others. She was in a bit of overreaction drama mode, and wanted me to come in and get the HRIG right then.  Back and forth, back and forth, we went, me calling Passport Health, etc.  She finally conferenced in some doctor from somewhere who insisted that I needed the HRIG.  At the end of the day, we left it that we were still checking with health departments or whatever on exactly what I needed to do, and they seriously acted like the doctor in Indonesia had been some sort of witch doctor following some sort of weird medical care.  In their heads, they probably pictured a straw hut and dirty needles, and wondered why I'd ever even venture out of Maryland in the first place, let alone the US.  That is how they were acting anyway.

Later, about 7:00pm, I got a call from my doctors office.  I had offhandedly mentioned to the county health department woman what my doctor's name was, and apparently the health department had taken it upon themselves to call her office without my permission and let them know the situation.  The poor admin at the doctors office had clearly equated my situation with Charla Nash, the women who had been mauled by a chimpanzee and later received a face transplant.  She was almost in tears at my "horrifying situation."  She asked if I wanted to come in right away.  Um, no.  It's Valentine's Day and the end of my first day of work after being gone for 3 weeks, and the end of the day where I spent most of the day feeling stressed out by the health department.  In fact, the health department caused me far more stress than the monkey did.  At last, I agreed to go get the stupid HRIG shot from the health department in the morning, and to go to my doctor in the afternoon to administer them.  You know, because after taking 3 weeks off from work, you want to take off more time to drive around getting shots you don't need.  Again, I remind you, the monkey didn't have rabies.


I went to the health department in the morning and met with the rabies lady.  She had, I kid you not, a file folder filled with printed out emails.  It was about 2 inches thick.  And the emails were all about ME.  Less than 24 hours had passed since I had contacted her.  She gave me 5 of the HRIG vaccines, because apparently it's administered by body weight, so I had to have 5.  I asked how much they were.  She evaded the question and told me that they would bill me later.  Then, she told me that she also felt that the monkey probably was carrying herpes, and therefore I should also get a prescription for Valtrex.  OMG.  I said ok, but I really meant "NO."

That afternoon, I left work early to head to my doctor to get the vaccine.  Apparently, her admin had really upped the urgency on my request, and so my doctor had read up on a million emails and papers that had been sent to her by the health department.  It was clear that she was going to do whatever the health department said.  She gave me the stupid Valtrex prescription (I don't think the monkey had herpes, but whatever), and had her nurse administer the vaccines.  The nurse went out and got a special mega-syringe and administered all five HRIGs in one shot.  Have you gotten a flu shot and had it burn for a second while it goes in?  Yeah, this was that same thing, but it took about a minute for her to squeeze all of that out of that syringe.  Into my butt.  In the end though, once it was over it didn't hurt anymore, and I went to my running store right after (it's in the strip mall next to my doctors office) and ran 4 miles.

Life went on.  I got the vaccine on the 17th from Passport health, and everything was fine.  Except that the health department wouldn't leave me alone.  A few days later, they called and suggested that I needed to get at least two more rabies vaccine shots (instead of the one that I had left) and then two weeks later a test to see if I was fully vaccinated or not.  It seems they were starting to feel like maybe the HRIG wasn't such a good idea.  At this point, though, I'd had enough of the health department and finally just decided to just get my last vaccine as planned and break up with the health department.

In the meantime, each vaccine was $265 from passport health, over $100 more than two vaccines cost in Indonesia.  My doctor charged me $120 to administer the HRIG, and since I am on a high deductible insurance plan, it was not covered.  I kept submitting bills to my travel insurance, and the travel insurance kept making me jump through hoops.  I had to produce more and more paperwork, until I had a file the size of the one at the health department's office.  Oh, and the HRIG shot?  $1650.  Not covered by insurance.  That was a fun bill to open.

In the end, I had $2700 in medical bills from this monkey bite.  The good news is that I've stayed on the travel insurance and done everything they've asked of me.  I've recouped all of it except for the initial 1,050,000 Indonesian Rupiah ($120 USD) bill from the medical clinic there because I have to have an Explanation of Benefits from my health insurance, and my health insurance is still stumbling over itself trying to produce this.  I've made 3 phone calls and sent two letters to them on the matter, and I still don't have an EOB.  I even asked them to just write me a letter saying that they won't cover it.  They are just....  irritating.

I won't truly be in the clear on the rabies situation for two years.  For two years, if I was exposed to rabies, I can still contract it.  So, I have until February 2013 before I know 100% that I don't have rabies.  But, I don't.  Trust me.

5 comments:

Nick said...

that is quite possibly the most appropriate photo for a blog post I have ever seen.

Brilliant piece Kim and great shot Todd.

Kandi said...

That sounds so frustrating! I don't think you have rabies either. I have heard that monkeys can have herpes B but I am lead to believe that's different than other types. I didn't think Valtrex would work for that but I'm not sure. My fiance works with monkeys and he gets vaccinated for herpes B periodically.

marathonmaiden said...

wow. talk about jumping through hoops! i am glad that you don't have rabies though.

Lacey Nicole said...

WHOA. what an ordeal for sure. and medical costs- WHOOOOOOOA nelly. i'm so glad you could use travel insurance and recovery most of that. remind me to 1. not visit the animals in other countries and 2. get travel insurance. yikes.

lindsay said...

Umm. WOW. What an ordeal!! Doesn't surprise me though that our health system is jacked up. I'm sure hearing "animal bite + foreign country" just freaked them out from the beginning. Glad you are ok! Boo for high deductibles... Story of my life too.

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