Monday, January 7, 2013

8:45 a.m. Training Center for Travel Medicine

National Taiwan University Hospital – Taipei

Things are a bit hazy this morning. I woke up at something like 3:30 this morning and then for whatever reason I couldn’t get back to sleep. I struggled for a while, but then I gave up and just got out of bed. I figured I’d go back to bed in a bit, but it never happened. Now the fatigue is creeping up on me.

I’m not entirely sure what is going to happen, but I am currently in the waiting area of the travel clinic. I’m pretty sure I have an appointment, but the paperwork is a bit confusing, so I’m not entirely sure I’m here at the right time and on the right day. Call it 80% sure on the day and 60% sure on the time. I think the clinic opens at 9 in the morning. And since I made my appointment a week ago, I think I will be one of the first to be seen. I think it says on my appointment sheet that I am number two on the list. We’ll see.

I’m scheduled to get my second Japanese encephalitis shot (second of three) and my second rabies shot (also second of three). I assume the routine will be the same as last time – see the doctor, put in an order for the vaccines, go down and pay for them, pick up the vaccines at the pharmacy, come back up and have the vaccines administered by a nurse, then pick up my vaccination booklet all properly filled out and signed.

I’m also going to ask about getting a typhoid vaccine. It came up during my last appointment and the doctor said that it wasn’t generally requested in Taiwan, so they don’t have the vaccine. But I would like to get it, so I’m going to ask today if they can order it for me from wherever these things come from. I assume you don’t get them on eBay or Amazon.

I have plans to ride my bike down to Alan’s Bike Shop today and get some work done on it. With that in mind, I spent a good chunk of yesterday working on the bike. My main task was to reattach the sensor unit for my Cateye cycle computer. I have a Cateye computer on my bike, but the plastic strap that holds the sensor in place on the front fork had fallen apart. I’d reattached it in various ways – with electrical tape and zip ties – but I’d finally ordered a replacement kit from Cateye. I’d had the kit for a while, but I just never got around to installing it.

It was not as easy as one might think. For one thing, the strap wraps around the fork and this fork has my front pannier rack on it. In order to get at the fork easily, I’d have to remove the entire rack. I didn’t want to do that because this rack is an extreme chore to remove and attach. This goes all the way back to my original frustrations with this bike – a bike I appear to have dubbed “the beast.” The beast was specially ordered and was supposed to have braze-ons for all the pannier racks. I was extremely disappointed when it arrived to see that it did not have braze-ons on the front forks. How Rocky Mountain could advertise it as a special touring bike when it didn’t have any braze-ons is beyond me.

I was semi-successful with the new mounting kit for the sensor. I didn’t have to take the pannier all the way off. I just loosened the bolts and pulled it away a little. Then I slowly cut away all of the old straps and tape and zip ties. I was astonished at how much gunk had built up underneath the tape. It had adhered to the forks and rust had begun and I had to go at it with a heavy-duty scrubbing pad to remove everything. Then I had to fiddle around for quite a while to get the new strap attached and in place. To my annoyance, I found that my “universal” replacement kit from Cateye did not actually work with my old Cateye system. I had to cobble together a combination of the old parts with some of the new parts. And once I had the sensor in place, I found that my Cateye computer wouldn’t register anything. I had the magnet lined up exactly opposite the sensor and close enough to it, but spinning the wheel had no effect. I did everything I could think off. I cleaned all the contact points. I adjusted the sensor and magnets. I changed the battery. But the Cateye computer would not work. I gave up in disgust and went online to try to find a replacement. The cheapest models were only about $20, so, to be honest, trying to repair an old model is kind of pointless. You might as well just get a brand new one and I resigned myself to doing that. However, about two hours later, I went back to the bike with renewed purpose. This time, I removed the battery from the Cateye and let the unit run down completely so that it did a factory reset when I reinserted the battery. Then I went through the installation procedures from scratch. That involved having to measure the distance my front wheel travels in one revolution and entering that number into the settings. And after all of that, for who knows what reason, the computer started to work. So that’s good. Now I don’t really trust it though. I might end up buying a new one anyway.

While I was doing this, I had to remove the wheel. And when I did that, I noticed that the front brakes were a bit dirty and in need of some maintenance. I removed them and methodically cleaned all the various bolts and washers and other parts. Each brake pad is attached with a set of six washers that have to be replaced in the proper order and orientation. Otherwise, you won’t be able to adjust the tilt and angle of the brake pad to match your bike rim. I just went about it slowly and surely and piece by piece so that I didn’t misplace or misalign anything. And when I put it all back together, the brakes were working very well. I thought about replacing the brake pads at the same time, but they seemed to have a bit of life left in them.

Later:

It’s now eleven in the morning and my appointment at the travel vaccination clinic is over. It was a successful and very interesting experience. I was number two in the patient list (though I think number one was just a placeholder – a fake to give the doctor some breathing room) and I was seen by the doctor at about 9:20. It was the same friendly doctor from last time, and she first asked me about any adverse reactions to the previous vaccines. I told her my funny story about the tape sticking to me and making me think that I was having an allergic reaction by pulling on the hair on my butt when I sat down. Not sure she got the funny side of it.

I can’t say that I have full confidence in this doctor. There is a certain vagueness to her demeanor that makes me think she isn’t quite on top of everything. I asked her this time about the typhoid vaccine. I wanted to know if she could order the vaccine for me. She just kept repeating that they didn’t have the vaccine. I got that information, but then she didn’t quite seem able to come to grips with my question about actually putting in an order for this vaccine. We went around in circles a couple of times. Then the nurse piped up. She and the doctor chatted for a minute or two in Chinese, and then the doctor turned to me and said that they’d just gotten a shipment of the typhoid vaccine in on Friday – literally three days ago. And they set me up for a typhoid shot along with my Japanese encephalitis and rabies shots. I was happy about that but also a bit confused. When the doctor told me they didn’t have the vaccine, it was always in the context of never having it in Taiwan, that people in Taiwan simply never got this vaccine. This Friday shipment, however, seemed to be routine – like they just restocked their usual supply. So it appears that they do normally have the vaccine. (It was on the price list along with all the others.) So why didn’t the doctor know that? If I hadn’t been proactive and asked about the typhoid vaccine several times and if the nurse hadn’t been on the ball, I would be going on this trip without vaccination against typhoid. And the doctor seemed totally unconcerned about that.

This reminds me of something that happened when I first went to the hospital and registered. I was filling out my registration forms at the registration desk. But before I finished the form, the woman I was dealing with was called away on some kind of emergency. She left her desk, and, I noticed, she left a medical document of some kind relating to a patient sitting right on the keyboard of her computer. When I finished my form, another woman took the completed form and put it on top of the other document on the keyboard. Then she called out to a third woman to come over and finish the process. This third woman came to that computer workstation and picked up my registration form along with that other document and went back to her desk. In her mind, they both applied to me. Who knows what was on that other form? An appointment for a heart transplant? A scheduled procedure for a leg amputation? It could have been anything, and this woman was now entering that information into the computer along with my form. Bad news. I spoke up again and again and again, but to no avail. I finally went back to the second woman and explained what had happened. She went to the third woman and looked at the forms and took away the second one and put it back and explained the mistake to the clerk. It just goes to show how easily something can go wrong even in a hospital. It’s a dangerous place for things to go wrong in because people have a natural tendency to trust doctors and are reluctant to speak up and monitor things for themselves.

With that incident in mind plus the oversight about the typhoid vaccine, I made up my mind to be more proactive. Therefore, when I did get my vaccines from the pharmacy and delivered them to the nurse, I asked specifically to see the contents of each bag – essentially making sure that I was being injected with the correct things. On the outside of the bags, I could see that everything was correct. They had the correct vaccine names written on them. However, the bags were sealed and I couldn’t see the actual little boxes that held the serum. So when I went to the treatment room, I wouldn’t let the nurse inject me until I had inspected the actual boxes themselves and confirmed that they were the correct vaccines and that they were within the expiration period.

It was actually even more complicated than that, because after I paid for my vaccines (NT$4,087!!!!! Ouch.) and went to the pharmacy to pick them up, they only had two of them there. They had the rabies vaccine and the typhoid vaccine. But they didn’t have the Japanese encephalitis vaccine. It was being delivered from somewhere else. The woman at the pharmacy said that I could take the two vaccines to the treatment room and be injected. Then in twenty minutes I could return and get the last one. I gave her my cell phone number and she would call me when it arrived.

So when I was at the treatment room, I made sure, rightly or wrongly, to point this out to the nurse. I had only two of the vaccines and I would be returning with the third. This confused her and set off all kinds of alarm bells – as well it should – and she went off to speak to the doctor and call the pharmacy to figure out what was going on. Everything was settled eventually, and I was given the two vaccinations in one arm. Then just as I was leaving the room, my phone rang. The third vaccine had already arrived – much sooner than expected. I went down and got it and went back to the treatment room. I asked again to see the contents of the bag before I got the injection. In this case, there wasn’t a box or any kind of packaging. The bag simply contained a tiny vial. I didn’t want to pick up the vial for fear of contaminating it with my dirty fingers, so I had to kneel down and bring my eyes to the counter top and as close to the vial as I could to try to make out was written on it. The English lettering was extremely tiny – so tiny in fact that none of the nurses could read it. By squinting, I could just barely make it out when the nurse held it up to my eye. And it was the correct vaccine as far as I could tell.

I was given the first two shots by one nurse and this last one by a different nurse – the same one who had given me my multitude of shots last week. This was also a bit confusing because she went to give me this vaccination in the same arm where I’d already gotten the first two. I don’t think it would have mattered a great deal, but it seems logical that I might as well get the third shot in my other – fresh – arm. What jumped out at me was that I was in the situation of having to give this information to the nurse. I had to explain which shots I had just gotten in which arm. The system had broken down to the point where I was being treated by two separate people and neither knew what the other had done.

I also noticed that the two nurses had different approaches. That puzzled me. When I presented my first two vaccines to the first nurse, she asked me for my name and birth date so that she could compare it to what was written on the prescription bags. Then she simply told me to roll up my sleeve and relax and then take a deep breath when she gave me the first shot. She covered the injection site with a bit of gauze and some tape. Then she went to give me the second shot in the same arm. This time, however, she forgot to bring any tape. She had to stand there holding the needle in place deep in my arm while she called out to another nurse to bring her the gauze and tape.

When I returned with the third vaccine and was met by a different nurse, she asked me for my name and birth date as usual. But then she asked me what I was being vaccinated with. It was like a test. She hid the prescription bag from me so I couldn’t read it and asked me what the vaccine was for. I’m not sure what the point of that was since you can’t count on all patients knowing the names of the vaccines. I’m (relatively) young and (relatively) intelligent and (relatively) on the ball, so I did in fact know what vaccine it was. I passed the test. But what if I didn’t know? What would that prove? If I didn’t know the name of it, she wouldn’t be able to administer it? And in this case, it wasn’t actually easy to know which vaccine it was what with all the switching around and having to pick one up later.

Then when the nurse gave me the injection (after I told her which arm to inject), she told me to put my hand on my waist, which, I assume, put my arm in the proper posture to receive the injection. The other nurse had not done it this way. It made me wonder if the hospital had a standard procedure for vaccinations and one of the nurses followed it and the other didn’t or if the nurses can just do it whatever way they wanted based on whatever training they got in nursing school.

The hospital was a completely different place this morning compared to how it was on my first visit on a Saturday and my second visit on a holiday. This was a regular workday Monday, and the place was crazy busy. The lobby area was clearly far, far too small for the volume of people flowing through it. And everything is right there in the lobby – registration, cashier, pharmacy, and everything else. It was jammed with people and I found it almost impossible to walk through it. Whatever wonderful qualities the Taiwanese people have, the ability to comport themselves efficiently and politely and with concern for others in tight physical spaces is not one of them. It was chaos with people going in all different directions, stopping and blocking everyone else, crowding forward, running into each other, going at different speeds. Add to that the huge number of wheelchairs, and it was a challenge making my way through it. I actually got run over twice by a wheelchair. Whoever was pushing it from behind just paid no attention to me and just ran it right into my back legs as I was walking along.

 

Here are the stats so far:

First Set of Vaccinations:              NT$7,732 (US$260)
Second Set of Vaccinations:         NT$4,087 (US$136)

Total So Far:                                     NT$11,819 (US$396)

This rather princely sum has gotten me fully or partially vaccinated against all of these bad boys:

Measles
Mumps
Rubella
Japanese Encephalitis
Polio
Meningitis
Tetanus
Diptheria
Pertussis (whooping cough)
Yellow Fever
Flu
Rabies
Typhoid

Getting vaccinated has certainly been much more expensive than I’d anticipated. And I’m not even done yet. I have to return twice more to get all the shots in the various series. That final figure will likely rise to about $500 US total. Yikes and double yikes. I had no idea it would cost that much. The rabies vaccine is the one that pushed the price over the top from moderately expensive to very expensive. That vaccine alone cost NT$5,250, or $175 US.

I guess that $175 could be seen as money well spent for a cyclist – particularly one that plans to do some cycling in India, a country that sees half of all rabies cases worldwide.

I just did a quick search around the Internet for information and I learned that rabies is 100% fatal for those who are exposed to the virus and do not get treated. I also learned that even if you get the rabies vaccine in advance (as I am doing) and you are exposed to rabies, you still have to get vaccinated again. You just have to get a smaller number of shots – 2 as opposed to 4 for someone who has never been vaccinated. That hardly seems like a big enough advantage to fork over the $175.

The key, though, is that you might be exposed to the rabies virus far from medical help. And even when you find medical help, depending on the region of the country you are in, they may or may not have access to the rabies vaccine. So it might take time to get the treatment. Having been vaccinated in advance is important in those situations. Also, you might not even recognize that you have rabies at first. The initial symptoms of rabies might be taken for the flu or some other illness. And by the time the symptoms show up, it is pretty much too late. I listened to one doctor on a video describe the rapid progression of the disease, which can result in death within 14 days. It was terrifying, and reassures me that my $175 is not going completely to waste.

 

Tags: bike, Bike Shop, Japanese Encephalitis, NT, Taiwan, US, Yellow Fever