Hospital Care For A Major Illness

[KED]

I have an ex-pat friend who has been teaching English in Thailand for 1 year. She is in her early 50's.

She does have insurance through the international school that she teaches; however, her financial savings are limited.

Recently, she returned from a 7 day trip to India and not long after her return she contracted jaundice. She went to a local hospital on Sathorn for a Hepatatis test but it came back negative. The hospital then did an ultra sound and found a growth on her pancreas.

So far, the hospital has been very attentive and informative and all the procedures have been professional. But, should she be diagnosed with cancer - is there a major difference between Bangkok hospitals for cancer treatment?

Obviously, she does not want substandard care since her life is involved, but she doesn't have the financial resources for treatment at a more expensive hospital if the care is the same.

She is an U.S. citizen and doesn't have any health care there - so Thailand, with her local insurance, is the best option.

Many thanks for any comments and information.

[chiang mai]

The TV Moderator Sheryl is best placed to answer this question, if Sheryl doesn't see your post and respond then I suggest you PM her for advice. Good luck.

[AyG]

It might be helpful to name the hospital at which she's currently being treated; people will have an opinion on the quality of cancer care there.

Your friend should also check the details of her local insurance to see whether she's restricted to named hospitals, or has a free choice within a certain budget.

[lopburi3]

As said Sheryl will be much better able to advise but type of hospital is important as most public hospitals test schedules may not allow prompt diagnosis and treatment in the cancer area from advise we received from senior doctors at such facilities.

[Sheryl]

Under these circumstances she woul;d be best advised to go to the Siriraj Hospital Cancer Center.

13th Floor, Chalamphaget Buiding

Siriraj Hospital 2 Prannok Road BangkoknoiBangkok Thailand 10700 Tel.(662) 419 4471-2

Care will be state of the art but there will be a lot of initial red tape to go through. If she can get a letter of referral from the hospital which has been treating her so far, that will help. Should also have a Thai speaker go with her for at least the first visit. The doctors will speak English well, but not the administrative and nursing staff so finding one's way around can be daunting at first.

Closer by would be Chulalonghorn Hospital, if she goes to the 13th floor she can arrange to see a specialist on a semi-private basis at their after hours clinic. Ask for either:

Dr. Varocha Mahachai

Dr. Ratha-Korn Vilaichone

if possible ( US trained top professosr there -- Dr. Varocha is more senior but Dr. Ratha-kmorn is younger and thus may be more likely to talk to her frankly) otherwise, a a specialist in pancreatic cancer. Here too a Thai speaker will be helpful initially.

Both of these are tertiary level government hospitals so her insurance should cover although she might have to be referred by the hospital she is registered with.

She'll get top quality care at either of these places in terms of prolonging her life and likewise in terms of cure if it turns out to be a nonmalignant condition. But I should warn that if it is pancreatic cancer the prognosis is usually terminal and within a fairly short time and she will need to think carefully about whether she wants to spend what may be the last months/weeks of her life in Thailand or back home. especially as Thailand is very weak in terms of palliative/hospice type care. There is some sort of hospice program recently started up at Chula but I don't know much about it.

A lot will depend on what supports she has available to her both in Thailand and back home...and how she feels about dying in a foreign hospital as opposed to at home with family (assuming she has family/friends back in the US).

Hospice programs in the US are very good and not all that expensive. If she does not own property etc, she can get onto Medicaid once her savings are exhausted, a process that hospice social workers can help with, they do it all the time.

Going back to the US and getting settled in to hospice is something she will not be able to do once the illness advances (again, I am assuming worst case scenario -- will not apply if the growth is not malignant) so she needs to find out ASAP if the mass is malignant so that she can decide accordingly. Unfortunately Thai doctors usually shy away from giving frank information like that so she will have to ask very pointed questions.

She can also consult either Dr. Varocha or Dr. Ratha-korn privately at Bangkok hospital, for which she'd have to pay out of pocket but it might be worthwhile on a onetime basis just to have their undivided attention. if so get get all tests done first and bring results with her so that she need pay only for the consultation.

I cannot stress enough that she may not have much time to figure this out and decide, and that unless she has family or really intimate friends here, she may be better off going back to the US. as the alternative might be a lonely death in a foreign hospital with less than optimal analgesia. If it is pancreatic cancer she will not be able to travel for much longer. This of course doesn';t apply if it is a benign condition, but unfortunately most pancreatic growths are malignant.

Feel free to contact me if I can be of further assistance

[KED]

Many thanks for all your assistance. She is overwhelmed and I am also trying to help her.

She is at Saint Louis Hospital and the care has been good so far. They are advising that she needs a whipple procedure and have advised they have a Chula specialist who would perform the operation.

Both of her parents are alive and live about 2 hours from the Mayo Clinic and they are trying to get her admitted there. The big issue is insurance since she is covered in Thailand from her employer but her husband in the U.S. is self-employed and she has no insurance there.

I also have read about pancreatic cancer and am saddened by the poor survival rate.

Thanks again to all, if we come across other hurdles I will check back and I will also advise if she continues her care here or back in the U.S.

Many thanks

[Sheryl]

St. Louis is a good hospital and would be well able to do the procedure. A Whipple is a major operation which attempts to resect the pancreatic tumor. it is appropriate only if the tunor has not spread beyond the head of the pancreas (and determining that would require a number of scans). Unfortunately even then the success rate isn't very good. Chemo and radiation are also usually needed, and even with the combo of surgery, chemo and radiation the prognosis is not good, although life may be extended by a few years in some cases and very rarely a cure effected if the tumor was very localized. Whipple should be done by a surgeon who has considerable experience with exactly that procedure.

She will certainly be better off if she can be treated in the US, the problem is going to be sorting out the paperwork required to get on Medicaid. Her parents need to talk with a medical Social Worker about this as soon as possible. If she is still legally married this complicates things considerably.

IMPORTANT: She should check on the Social Security website to see if she is eligible for disability benefits and inform her parents accordingly as the medical Social Worker will want to know this.

She could consider undergoing the surgery, chemo and radiation here in Thailand and then returning to the US after that. The risk is that it might all leave her to weak to travel, but being only in her 50's there is a chance she'd have at least a temporary return to health sufficient to go back. Longer term she is definitely best off to be in the US on Medicaid since the odds are she will need hospice care in future and Thailand is not a good place for that. Plus she may prefer to spend what time she has left, be it months or a years, back with her family.

If she is a good candidate for a Whipple procedure she shouldn't wait long for it. the issue is that "if". Thai doctors are not very good about giving frank bad news nor at involving patients in decision making. I suggest she take all her records to one of the 2 docs mentioned for a second opinion and ask them very specifically what her odds are with and without the surgery, explaining that she understands the overall prognosis isn't good and wants to kn ow if it is really worth going through the pain etc of a major surgery. If the tumor is really limited to the head of the pancreas then it probably is, otherwise maybe not.

.

[KED]

Sheryl, I sent a private message to you thanking you for all your valued and detailed information.

My friends parents and family felt it was better that she fly back to the U.S. immediately and continue whatever care necessary there - even though there will be financial hurdles they felt that since her family would be able to act as caregivers between hospital visits that was the best option.

St Louis Hospital was marvelous and the personalized care of the hospital nurses was unmatched - they were personal and compassionate. The doctors were very professional and knowledgeable; however, we did notice a hesitancy to share much information to base future decisions on.

The only other issues were when trying to get as many of the CT skan, Ultra sound and endoscopy images for the U.S. hospital, we thought the doctor had agreed to give us copies of all the tests; however, when checking-out of the hospital the nurses said that this was not possible. They called the doctor who was then out of the hospital and through some miscommunication he advised the nurses that he had not agreed to this at all. We were allowed to take photos of the images and will contact the doctor later to see what is possible to bring to the new doctors in the U.S.

Finally, the hospital bill was substantially lower than any similar care in a western country and from our perspective there was nothing lacking in her care; however, while the actual stint placement (due to the blocked liver duct) and endoscopy was only 30,000 baht and the CT scan only 1,500 baht, and her anesthesiologist bill was only 7,000 baht - there were three bills listed as Medical Equipment for 49,000 and 32,000 and 29,000 baht. She was in the hospital for 3 days and had IV but the only actual procedure was the endoscopy/stint - we weren't quite clear on these additional Equipment charges which seemed so much more substantial than any of the other billing items.

We had the Thai Human Resources manager speak directly to the billing department but he wasn't able to get much clarification on these items. Not to complain too much since this was a life or death issue, but anyone have any ideas about these listings / charges?

[Sheryl]

It is probably the stents but ere there 3? As that is about the only medical equipment that runs that high in cost.

She can definitely get the original scans to bring with her to the US and by law the hospital has to provide it. If she hasn't left yet try to sort this out so she can bring it all with her.

[Sheryl]

P.S. One thing to look into when she is back in the US is clinical trials as these usually provide care free of charge. not likely to cover surgery though. If you let me know what state she lives in I'll research it a bit for you.

[KED]

Sheryl,

Yet again your quick response, and detailed information continue to be beyond expectations.

Her parents live in Minnesota and her husband is in Tennessee -

The doctor is back on duty at 7 PM tonight - I will try to call him and see what images we can get to bring to the U.S.

[KED]

We did get the images from the CT scan and ultra sound - but nothing from the endoscopy - we just don't know what information the U.S. doctors will need - but we did also get the doctors card with phone and email.

[Sheryl]

Usually the endoscopy is on a CD. Might be possible to get it sent electronically.

This is the link for info on medicaid in Minnesota. Relatively speaking, Minnesota is better than most in the benefits it provides and in becoming eligibility. And, the Mayo clinic accepts Minnesota medicaid. Forget Tennessee, the southern states are atrocious in benefits.

http://www.dhs.state...Name=id_006254#

Her biggest obstacle will be her husband if they are still legally married, as their joint income would then be the basis for eligibility rather than just hers and thus likely make her ineligible. By herself and not employed she'd likely easily qualify People actually get divorced to deal with this problem.

There3 is also a special low copst insurance type program called "Minnesota Care" that doesn't exclude pre-existing conditions but one has to have lived in Minnestoa for 180 days top qualify. Possibly if she maintained a MN address she can manage that.

A Medical Social Worker can advise further on these options. All hospitals and home health agencies have them on staff.

There are several clinical trials currently recruiting in Minnesota but eligibility varies. The one that catches me eye, assuming she is a candidate for suirgery, is this one:

http://clinicaltrial...nnesota&rank=49 This is testing the giving of chemo prior to surgery,. It's a phase 2 open label study which means no control group or risk of placebo.

There are others as well. this is the linkl to the full listing. She shouyld scan don for theo nes listed in green as recruiting and then look at the criteria. Be alert to those that are described as double blind as they may have a placebo group.

http://clinicaltrial...ancer minnesota

If inoperable (or if has surgery that wasn't able to remove all), http://clinicaltrial...nnesota&rank=57 and several others. Altho she was advised to have a Whipple in Thailand we cannot necessarily assume it is really indicated as thai doctors have a tendency to do useless treatments rather than admit that a prognosis is untreatable.Maybe she really is operable, but need to reality check that with US physicians. Most US docs are trained to be frank with patients and to fully involve them in the decision making.

[KED]

Just a little update. I saw my friend off at the airport this morning. She will reach Minneapolis in 24 hours and in two days she has her first meeting with the Mayo Clinic to review the medical history from the Thailand hospital. I will follow up here to see what Mayo says versus what she was advised by Saint Luis Hospital.

All the best.

[phuturatica]

And as usual Sheryl never fails to amaze me with her information and help.

KED - I hope everything turns out ok for your friend. My thoughts are with you and her.

[chiang mai]

And as usual Sheryl never fails to amaze me with her information and help.

KED - I hope everything turns out ok for your friend. My thoughts are with you and her.

+1

[MrRed]

If there was one lady in Thailand who i would like to have her number it is Sheryl.

What a diamond

[KED]

Okay...Here is the update. She has cancer of the duodenum and will be receiving chemo for 2-3 months before they do surgery for a more successful outcome. There is an affected lymphnode that is up against a major artery and they want to remove it at its smallest form. She hopes to have whipple surgery sometime in Aug

[Sheryl]

Thanks for the update. If the primary cancer is in the duodenum rather than the pancreas her prognosis is better than it would have been had it been a primary cancer of the pancreas.

Some good resources:

http://www.cancer.gov/cancertopics/pdq/treatment/smallintestine/Patient/page1

http://archsurg.ama-assn.org/cgi/reprint/135/6/635.pdf

If she has not already she should meet with a medical Social Worker and in addition to options for payment of medical care, see if she is qualified for Social Security disability and if so, start the application process. She is in for a long haul and the payments (which take at least 5 months to kick in) will be helpful.

All the best to her.