As my trip around the world continues, I’m learning more and more about the challenges of taking diabetes with you on the road. This recently became apparent when, for reasons I still don’t quite understand, I decided to try to get a Hemoglobin A1c test performed in Tallinn Estonia — at 7 in the evening.
My thought process, as I recall it, was as follows: it has been nearly three months since my last A1c. I am planning on traveling for the next three months as well, and my destinations — Russia, Mongolia, China — are not known for having the finest medical facilities. Ergo, I might as well try to get one now. I didn’t know so much about how Estonian medical care compared to its counterpart in Moscow, but I decided it was worth a try — so I called an English-speaking medical hotline and was advised to go to an emergency room. When should I try? “You might as well go now,” the guy said. “You’ve got about two hours till rush hour.”
There was really no reason to go right then, seeing as how it was already six in the evening and my A1c was a less pressing cause than dinner. But, figuring there was no time like the present, I called the emergency room and decided to do it anyway. The following is my journal entry from the waiting room:
August 2nd, 2010
I’m in the Tallinn Central Hospital, waiting for my blood to be drawn for an A1c test. Or at least, I think I’m waiting for an A1c test — I’m not very confident they understood what I was talking about, so I may very well be waiting an hour for a very expensive finger prick.
Getting here wasn’t easy — the cab driver, after trying to overcharge me, dropped me off at a non-descript building in what looked like an apartment complex. Inside, I found a receptionist who, when I asked her where I could go for “emergency,” pointed me upstairs. This seemed odd — there were no ambulances or, for that matter, other patients — just another woman sitting at a desk who took one look at me and summoned an English-speaking colleague. I tried to explain to her that I wanted a blood test for diabetes; she looked at me, confused.
“Why do you need it? I think you should come back tomorrow,” she said.
“But the person on the phone suggested I come in tonight.”
“He did?”she said, perplexed. “Are you pregnant?”
I hadn’t been entirely convinced she knew what I was talking about to begin with; now I was doubly unsure.
“Are you sure you called this building?”
“I am looking for the emergency room,” I said.
“Ah,” she responded, pointing across the courtyard. “That is the building over there. This is the women’s health clinic.”
At least that explained the pregnancy test. We laughed, and I headed over to the correct department, noticing en route a series of large photographs of pregnant women stroking their stomachs that I somehow had missed on the way in.
And so to the emergency department! Here there was a paramedic at the door and a man lying ont he ground next to a bicycle — a more promising entrance, to be sure. The waiting area had several people standing around but no line — and it turned out that these were indeed the people I had spoken to who had instructed me to come in. And . . . they had no idea what I was talking about.
Did I want a glucose test? No, I wanted a hemoglobin A1c. I wrote it down, using as many variations and explanations as I could think of. “It is three months,” I said. “A three-month average.” I pulled out my own glucometer to try to demonstrate the difference.
“What is that?” asked the nurse, who was a young woman with a stern demeanor who somehow managed to make every question sound like she was yelling at you.
“A glucose meter,” I said, more than slightly disturbed by the question. “This is right now. Hemoglobin A1c is three months.”
She finally took a piece of paper I handed her and read my request out loud to the lab, spelling HBA1c out loud several times before hanging up and announcing “We will do that” before telling me I would wait one, maybe two hours. How much would it cost? “I do not know. Perhaps you can ask the doctor. Room 6.”
I thought there was supposed to be a triage system — which would have sent me to the room frequented by people with minor bruises — but instead, room 6 is labeled “EMO INTENSIV” and has several beds on either side of the room separated by curtains, with vital monitors beeping and bare feet peeking out of the sheets. There’s a table of nurses in the middle of the room behind computer screens. Despite the bare feet, nothing critical seems to be happening — perhaps there’s a super intensiv unit down the hall.
When I arrived, it was very unclear what to do — there’s a waiting bench in the hallway but it’s not visible from the nurses’ station. With no apparent way to “check in,” I just stood in the doorway until someone noticed me — and told me to wait outside. But no sooner had I sat down than someone else called me back in — the woman behind the counter who had suggested I speak to the doctor. Apparently, she was the one who would be drawing my blood. And she didn’t like me.
“Sit on couch,” she said. “I do the test.”
With nothing to confirm that the test in question was actually the test I was trying to get done, I tried to figure out what the best method would be for determining this without insulting her. It reminded me of the chapter in Malcolm Gladwell’s Outliers where he talks about how many plane crashes have been caused by flight crews showing excessive deference to the captain. For example, a crew member will say something oblique, like “Wow, that de-icer doesn’t seem to be working too well!” instead of “Our wings are frozen and if we try to take off right now, we will die.” Then the plane crashes.
But nothing I said worked. “I do the test for you!” she repeated, in response to my question of what test she was talking about. “And after you will wait one hour. Out there!” She pulled out a tourniquet.
This didn’t really make sense, considering that I would have already had the blood drawn. Why not just pay and call them for the results.
“May I call you?” I asked politely.
The look in her eye made it clear that this would not be possible.
“You must wait one hour here.” She pulled out a needle then, thinking twice, recapped it and picked up a bottle of what I really hope was disinfectant spray. She was — both literally and metaphorically — after blood.
I knew I was pushing my luck, but I couldn’t help myself. “Do you know how much it will cost?” I asked, hoping to perhaps get an answer before I allowed my vein to be punctured. (It’s good to know that we’re not the only ones with an opaque pricing system.)
No. She did not. Instead she glared at me, repeated that she would do the test, and reached for my arm. Figuring it would be better to save the follow-up questions for after she’d stuck a needle into my arm, I allowed her to fill two vials from my left arm (after spritzing it with the unidentified contents of the bottle — they did not smell like alcohol) and handed me a paper towel, no bandaid, to cover the puncture.
“Now you wait. OUT THERE!” she said, just in case her earlier message hadn’t made it through.
It has now been one hour and, aside from someone carrying a little orange suitcase with a biohazard symbol out of the room about a half hour ago, I have no indication of whether my blood has actually left the room. Worse, my English-speaking nurse, horrid though she may have been, has vanished. I don’t get the sense that the rest of the staff will appreciate me poking me head back in the room, but I also don’t have any confidence that they know what the test is or are actually doing it. Do I look inside?
It is now several days later and I can tell you, dear readers, that I did look inside — quietly and, I thought, politely — and promptly established hostile relations with the entire nursing staff. Oh, how they did not like me. Eventually I got the nicest member of the bunch — a young man wearing a bandana and white shorts whom I’d seen walking up and down the hallway carrying endless small cups of water to unidentified locations (I think he was bored) — to confirm that I could indeed leave the hospital and call them to find out the result. Could I pay before I left? No. My case was still open. I would have to come back. But at least I was free.
So I left. And when I called back that evening and they told me what it was, I tried again to pay. “May I pay by credit card?” I asked the woman on the phone.
“Yes. But you must come here.”
“May I give you the number over the phone?”
“No,” she repeated. And then, just for kicks, “This is not a hotel. This is hospital.” She was emanating hate — I’m sure I came across, albeit unintentionally, as an English-speaking bitch. But then again, I hadn’t said anything I’d considered irrational. It’s like when I called Iceland Air to ask what would happen if our flight were cancelled by the volcanic eruption, and a customer service representative told me that she couldn’t “call up the volcano and ask when it would be erupting” and then hung up.
Oh, it made me mad — especially because my A1c was one of the worst I’ve had in years (transferred diabetic rage = never a good thing). I considered not going back to pay — I mean, dude, how many times could I try to get them to let me give them money — but morality prevailed, and the next day I walked over with Peter in the middle of a rainstorm to pay for the test and (god help me) try to get an English bill so that I could attempt to get insurance to reimburse me for it. (As anyone who has dealt with international claims forms knows, they are insistent that you give them something in English.)
Needless to say, this did not go well. The woman behind the desk started off friendly, but as soon as I asked if I could see the bill before paying it — a wise move, since there was what appeared to be an entire blood panel on there, with four tests repeated twice — she refused and, to my horror, called back the nurse from the night before.
I tried to ask her what she had charged me for and why there were so many tests. She glared at me and told me to pay. We went back and forth several times before, giving up, I asked if she would please write a sentence — which I wrote on a piece of paper — saying what test I had gotten and how much it had cost, so that I could send it to the insurance company. No, she would not. Instead she started yelling.
“YOUR DOCTOR WILL TAKE THIS!” she yelled. “HE WILL TAKE IT!”
By now, this was becoming a scene; a man suddenly appeared at my left and, with breath that smelled like straight alcohol, tried to help me translate.
It quickly became clear that while she understood what I was saying, there was no way this was going to happen. When I tried to explain that the note wasn’t for my doctor — and besides, I don’t even have one at the moment since we moved from California — she even threw in a little barb (“Why do you not have a doctor IN ENGLAND????”) before glaring some more.
I finally just handed over my credit card. I’m happy to report that my sodium levels appear to be within a normal range — but less happy to report that, as with the other charges on the bill for tests I did not request, I was charged twice.
A word of actual advice: if you are trying to get an A1c done abroad, make sure that the results they give you are in the correct units — most countries use the mmol/l metric instead of the American mg/dl. The mmol/l numbers inconveniently overlap with A1c measurements (i.e. a 6.7 could be either one) — so I went through a moment of thinking my A1c might actually have been my current glucose number, measured differently.
You’re braver than I am! We travelled for 6 months and I didn’t even consider getting my HbA1c tested – South American and South East Asian hospitals scared the living daylights out of me…