Med-evac 101: How does it work?

Peace Corps often gets a bad reputation for their treatment of Volunteers during potential medical emergencies or medical evacuations. (Often because we only hear about the cases that result in life-long conditions or worse.) I’ll admit that I had a rough go of getting my wisdom teeth extraction approved, but when I eventually did end up in Pretoria, South Africa, the entire process was smooth!

Unfortunately, that month of back-and-forth between medical officers in Washington D.C., Rwanda, and South Africa was pretty emotional and my fate in the Peace Corps was uncertain. So here’s how it all went down for anyone out there looking to self advocate for medical care during Peace Corps.

Medical Tasks Before Departure (a few months before hopping on the plane) – I expressed jaw pain to the dentist during my check-up for final Peace Corps approval. He did an x-ray and determined that all four of my wisdom teeth had made an appearance but were not moving around enough to warrant extraction.

Mid-Service Medical (around August 2015) – I had a dentist appointment in Kigali that was less than stellar, but found no cavities (yay!). My jaw was beginning to hurt more and more and I was getting headaches once or twice a month that I attributed to my shifting teeth. *** This is the point at which I should’ve expressed my jaw pain (to both my PCMO and my dentist). Instead, I assumed I could push off the extraction until I was less busy with projects.

Beginning of March 2016 – With the jaw pain and headaches getting worse, I reached out to my PCMO (Peace Corps Medical Officer) and he agreed I should see the dentist as soon as possible.

Beginning of March 2016 – I had been scheduled for an appointment immediately and headed off the dentist. I spent about five minutes in the dreaded dental chair before the dentist also agreed that my wisdom teeth probably needed extraction. He said that I would need to set up an appointment for a panoramic x-ray (as the machine was currently not working).

Mid April 2016 – By this point, I’d been to the dentist’s office no less than four times. This was pretty difficult to arrange for a Volunteer who lives four hours away from the capital. Each time I would show up at the dentist’s office, I was told that the machine was either “out of order” or the image capture software was not working. I was getting pretty frustrated that Peace Corps continued to send me to the dentist without first confirming my appointment…and that the dentist’s receptionist had failed to call Peace Corps to let them know the machine was down. I could’ve avoided multiple expensive trips to the capital. Each time, I took note of just how many days I had left until my COS date (which was…and still is until I sign some paperwork…August 23rd, 2016). I knew that Volunteers are put on a travel restriction when they reach ninety-days-until-COS; I was scared that restriction would interfere with my potential med-evac.

April 18th, 2016 – I’d finally gotten my panoramic x-rays back and they were submitted to Washington D.C. the next day for med-evac approval. It was plainly clear in the x-ray that all four of my wisdom teeth were impacted, but that the bottom two were interfering with the nerves in my lower jaw. At this point I had 127 days left until my official COS date (well outside of the 90-day travel restriction period).

April 19th-27th, 2016 – I was told that “someone” along the medical chain had denied my med-evac request as they would not approve the wisdom tooth extraction so close to my COS date. Given that my PCMO had just told me that the cost of extraction would run an upwards of $9,000 in the States, I was freaking out. (I don’t even run in the same circles as people with access to that kind of cash.) My PCMO was freaking out for me. He was incredibly supportive and sent a pointed e-mail back asking for reconsideration since my COS date was well beyond 90 days from that point. He was a strong advocate for me; thoroughly explaining my jaw pain and the series of delays at the dentist that kept pushing back the date of the med-evac request.

The back-and-forth that ensued consisted of my PCMO advocating for the med-evac and being told no by some medical official or another (maybe in Washington, D.C., maybe in South Africa). At one point, my PCMO received an e-mail that laid out my options:

  1. Do nothing and COS like normal. Receive a medical voucher and, when I return to the States, have the extraction…possibly front the money (ha. ha. ha)…and hope that the State Department would reimburse me. I was told this was a lengthy and often unsuccessful process.
  2. Be med-evaced to my home of record (Kelseyville) and Peace Corps would pay for the procedure. Following the procedure, I would be unable to return to Rwanda and would be medically separated.
  3. Be med-evaced to my home of record, Peace Corps would pay, and I would be granted early COS (Close of Service) at the end of the 45-day medical hold period.

Option #1 was clearly not an option. I had no way of knowing how the payment process would work and I just couldn’t risk having to pay that amount of money or live with the pain. Option #2 was not an option as there was no way I would take anything less than official COS (Close of Service). I’d been in Rwanda for 23 months at that point and had had a service’s worth of accomplishments built up. I wasn’t about to be medically separated at the home stretch. So, Option #3 it was. I tried to mentally prepare myself to leave Rwanda at the end of May, when they would med-evac me back to California. That would’ve allowed me a little less than one month to pack up my entire life, tie up my secondary projects, and say goodbye to everyone who had come into my life over the course of the last two years. Instead, I broke down into tears in my PCMO’s office and basically didn’t stop stressing out for the next 12 hours. I was not ready.

April 27th, 2016 – I happened to be in the capital for a committee meeting, so I met with my PCMO about my options. Recognizing my hesitancy, in no uncertain terms, I was instructed to bring my Country Director into the mix. Since medical records are obviously confidential, she was unaware of the situation (though she has the most pull at this Post). I gave her a call and explained the whole situation; I also told her (and my PCMO) that they had my permission to discuss the details of case with one another. I wanted everyone involved to have as much information as possible in order to fight the med-evac denial. My Country Director graciously offered to take this on and advocate on my behalf.

April 28th, 2016 – I  walked up to the medical office to get an Aspirin for my jaw pain and as soon as I did, was greeted by a smiling PCMO who said, “Follow me.” He led me to his computer and read aloud a two-sentence e-mail that said, “PCV Melissa Denton is approved for med-evac to Pretoria. Her med-evac confirmation number is…” You’d have thought I won the lottery by my reaction. My PCMO and I hugged it out and he explained what had happened to change the RMO’s (Regional Medical Officer’s) mind: My Country Director had poured over every Peace Corps manual she had in order to find the exact wording on medical evacuations and their relation to COS (Close of Service) dates. Whatever she found and included in the e-mail to the medical officers was apparently enough to have the RMO (Regional Medical Officer) immediately approve my med-avac and wisdom tooth extraction. I called my Country Director, elated, and thanked her for whatever she wrote on my behalf, explaining that it’d worked and I was good to go for the procedure. I also profusely thanked my PCMO since none of it would’ve been possible without his  suggestions on how I dealt with the bureaucracy of it all.

May 10th, 2016 – After thirteen days of stressing that I might not actually get on that plane (who knows what could happen while they were supposedly scheduling my flight to Pretoria), I headed to the airport!

May 11th, 2016 – I woke up in the comfiest bed, smelling bacon, in the cutest little guesthouse in Pretoria, South Africa. (Shout out to The Rose Guesthouse!) This place serves as a guesthouse to all PCVs coming for medical evacuations from East and South Africa. (West Africa countries evacuate to Morocco for medical care, while European and Asian countries evacuate to Thailand. Obviously, Latin American countries evacuate back to America.) I met some of the other PCVs in town for medical care while nomming on delicious (and free!) french toast and coffee. Around 8:30 every day, a Peace Corps driver is sent to pick up all the PCVs who have to head to the office…so away we went! (I should also mention at this point that there was another Rwanda PCV in Pretoria while I was…which made the whole transition really easy…thanks, Henry!) After I saw the RMO (Regional Medical Officer), Dr. Erfan, I was scheduled for an appointment with Dr. Manfred Swanepoel, Maxillo-Facial and Oral Surgeon the next day.

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Home sweet home for ten days…

May 12th, 2016 – I was driven forty-five minutes away to Unitas Hospital where I met with Dr. Swanepoel. This guy is the most interesting character, y’all! I was briefed by Dr. Erfan the day before that he is not a talker…but boy was that an understatement. After spending approximately fifteen seconds in Swanepoel’s super fancy ortho surgeon chair, he told me that my bottom two wisdom teeth needed to be extracted. However, he also explained that my jaw pain was not a result of the shifting teeth…but rather of knots in my maxillo-facial muscles. Apparently I was to massage my jaw muscles daily or I could be referred to a facial masseuse in America for when I returned from service. Anyhow, I was scheduled for wisdom tooth extraction for the next day at 11:00AM.

 

May 13th, 2016 – Surgery day! I was again driven to Unitas Hospital where I was admitted around 10:30AM and sat in a tiny hospital gown feeling entirely too naked for three hours until I was wheeled into the operating room. Let me just say, this is where my nerves of steel went right out the window. I was excited that I’d be under general anesthetic as I already have a fair hatred of the dentist…but being wheeled into the operating room was a tad bit scary. I had an IV drip put in and then waited for the gas to put me under. Juuuust as the mask was going over my face, the anesthetist made a joke about Michael Jackson and comparing me going under to MJ’s drug use. (Great timing, bro.) I was forced awake just thirty minutes later, with the procedure done, slurring my words as I tried to thank all the nurses around me. I had a completely numb jaw, so I probably sounded like a complete idiot.

May 13th-15th, 2016 – I laid in bed, doped up on the most minimal Codeine, while the rest of the merry gang (the other med-evaced PCVs) went about their weekend…rugby games and eating solid food and such.

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I laid in bed for most of the weekend post-surgery…

May 16th, 2016 – I went to the Peace Corps office and met with Dr. Erfan for my check-up. I explained that I felt great, the surgery went fantastically, and I was ready to go back to Rwanda. He said, “Hold up”, and I was scheduled for my actual follow-up with Dr. Swanepoel on Wednesday.

May 17th, 2016 – I went to the famous Lion Park in Pretoria with Henry (fellow Rwanda PCV) and Jatin (Namibia PCV)!

May 18th, 2016 – After my final forty-five-minute drive out to Unitas Hospital, I waited about an hour until I was ushered into Dr. Swanepoel’s office. He spoke to me for literally two minutes and then I was free to go back to the guesthouse. I waited another hour for the driver to return (pretty common, since our AMAZING driver George was responsible for taking all six of us med-evaced PCVs to and picking each of us up from our appointments and physical therapy sessions and surgeries and such.)

May 19th, 2016 – I ate. A lot. And shopped for food. A lot. At this point, three of the other PCVs who had been med-evaced had either returned to the host countries or been sent to America for further treatment. The rest of us pigged out on delivery Dominoes.

May 20th, 2016 – After painfully saying goodbye to my perfect little room at the guesthouse, I got back on a plane to Rwanda and was back in my regional town by 4:00PM that night.

And that’s it! That’s how my med-evac played out.

I do want to mention that, though my experience with staff at my Post was beyond supportive, that’s not always the case with PCVs. Some of the other med-evaced PCVs had an even worse time getting their med-evacs approved…while others were sent immediately to South Africa upon injury or diagnoses and then directly back to America. Every med-evac is different, as it should be based upon the case and the individual. But not having a consistent, streamlined plan of action can convolute treatment for some PCVs who don’t have obvious injuries or symptoms.

I guess my point is…that med-evacs can happen, but sometimes you’ve got to fight for your voice to be heard. We often get placed into these childish roles while serving in the Peace Corps. We’re babied (whether by choice or not) and that’s frustrating when it comes to our own medical care. We should be able to advocate for ourselves, but are instead sidelined while officials who don’t even know us decide what’s best for our bodies. It’s important, if you feel like you need medical attention, to consistently and professionally advocate for yourself. The PCMOs don’t know your body like you do. And the RMOs and officials in D.C. certainly don’t even know you. Reach out to someone who can attest to your character (like your PCMO or your Country Director) and ask them to further advocate if you’re not seeing the results you want.