Tag: health

Shaky Business

Early in the pandemic I avoided seeing my patients for a while, except with virtual visits. After returning to the office I tried to maximize the distance, and minimize the duration of contact to lessen both our risks.

As the pandemic has progressed, both my patients and myself have gradually become more relaxed. I think this is from a combination of vaccinations, having effective treatments, and just habituating to the situation. Initially I had stopped shaking hands, and my patients stopped trying to shake mine. But eventually some did, with either a fist or elbow bump, or sometimes a full hand shake. Some would follow my lead but remark about how they guess we are no longer shaking hands.

A few months ago a plumber came out my house to replace a sprinkler valve system that sprung a leak after an earlier freeze. When he arrived he stuck his hand out to shake. Not wanting to be rude I shook his hand, then was careful to make sure I didn’t touch my face before washing my hands.

Not longer after, someone came out to pump our septic tank. The same thing occurred. No offense to those in the sanitation field, but if you’re a germaphobe, rationally or not, shaking hands with someone who empties tanks with human waste does not sound like a good idea! But again, I didn’t want to be rude, so I did so.

After those encounters, I pondered what I should do with my patients. Having seen plenty of guys in public bathrooms walk out without washing their hands, or with just a cursory rinse, and knowing that most people, myself included, often touch their faces unconsciously, which is how diseases often spread, I’m a little leery of shaking anyone’s hands. Pre-pandemic I overrode those concerns and did so anyway, for the social bonding benefit, but now it’s more socially acceptable to not shake hands.

In the office we wash our hands often, even pre-pandemic. We’re taught to gel in, gel out. That means you use alcohol gel to wash your hands when you walk in to see a patient, then again as you leave the room. Even with that I usually put the gel in one hand, open the door with the other (who knows who touched that door handle last), then rub my hands together as I walk into the room (which also demonstrates to the patient that I washed my hands). If I then shake their hand (and anyone else they came with), then I feel compelled to wash them again lest I touch my face during the visit, or just to avoid potentially contaminating the keyboard (though my nurse does wipe it down often). That can easily add up to washing my hands over 50 times a day. Certainly the alcohol is a lot faster than using soap and water, but is more drying on the skin.

So where does that leave things? Basically I shake hands when my patients offer it, and occasionally other times, as I continue to weigh the pros and cons. I suspect after the current wave of infections declines I’ll relax more and be able to shake off the feeling of impending doom.

Speaking Truth to Power

On 4/18/22, a federal judge in Florida struck down the CDC requirement of wearing masks on trains, planes on domestic flights, and other public transportation. This came less than a week after the Centers for Disease Control extended the mask mandate through 5/3/22. Immediately a number of airlines, including Delta and Alaska, announced that they were removing the requirement.

She made this ruling before a hearing was held, and nationalized the ruling rather than limiting it to the plaintiffs who had filed the case. In addition the mandate was probably going to go away in 2 weeks in any case.

Who was this federal judge? It was Kathryn Kimball Mizelle, appointed for a lifetime position at the age of 33 by President Trump, despite that she had never tried a case, and the American Bar Association rated her as, “Not Qualified.”

Just because she had the power to make this ruling, doesn’t mean she’s right. Of course when it comes to the law, I’m even less qualified than this judge, but from a medical point of view, we’re still in a pandemic. I, for one, will continue to wear a mask in an airplane, at least for a while, even if it’s just to avoid the common cold.

Omicron OMG!

Just when it looked like it was going to get safe to get back into the water, now we have a new COVID-19 variant with which we have to contend. Named after the Greek letter Omicron.

We don’t have enough information yet to know how serious of a threat this is, and whether it will significantly change what we do, but at best it’s tiresome news, and at worst it may cause significantly more cases.

For now, continue to wash your hands frequently and wear a mask in crowded places. If you’re fully vaccinated then there are a number of considerations about which situations it’s safe to not wear a mask. It includes the number of cases where you live, the chances of being exposed to those not wearing masks, and you personal risk.

Getting a booster is now a much simpler process. According to the CDC, if you’re 18-years or older and it has been 6 months since you last Pfizer-BioNTech or Moderna vaccine, get a booster. If it has been at least 2 months since a Johnson & Johnson vaccine, get a booster.

You may mix and match boosters. If you had a Johnson & Johnson vaccine, you will probably get a better response from having a Pfizer-BioNTech or Moderna vaccine booster compared with another Johnson & Johnson booster.

Stay tuned!

A is for Aspirin

You probably recently read in the news something about aspirin recently, and maybe you’re wondering if you should stop taking it, or you went ahead and already did. I know lots of my patients have been asking me.

The article by the U.S. Preventive Services Task Force talks about the use of aspirin to prevent heart attacks and strokes. They said for primary prevention (meaning to prevent a first heart attack) they recommended shared (between patient and their doctor/provider) decision making for starting aspirin in 40 to 59-years-olds with a 10% or greater risk of having a major heart event (such as a heart attack) in the next 10 years who do not have increased bleeding risk. They recommended not starting aspirin in those 60 and older who have less than a 20% risk.

There are a number of key points.

  • This is a draft recommendation. There is a public comment period and changes will be made before it’s finally published, probably in 6 or more months.
  • The recommendations only apply to starting aspirin.
  • The recommendations do not apply to people who have previously had a heart attack or stroke.
  • They make no recommendations about stopping aspirin other than considering stopping at 75 years old for primary prevention.

For patients who have had a heart attack, stroke, or peripheral artery disease (blocked artery to one’s arms or legs), the benefits of aspirin generally outweigh the risk of bleeding.

The decision to use any medication is always a balance of the benefits versus the risks (and sometimes the cost). Why the change in recommendations? Well in part we generally get progressively better as we accumulate more scientific information. But probably in this case it’s more due to treatment changes. When the original recommendations came out to use aspirin for primary prevention we did not have very good treatment for the conditions that cause heart disease, particularly cholesterol. With improved treatment, there is less incremental benefit from aspirin, yet the bleeding risk remains. That may shift who we should treat.

For now, I’m not recommending any changes before the final recommendations come out. Aspirin was first recommended for primary prevention over a century ago! If taking aspirin was that risky we’d have known there was a problem long ago. I don’t think there is any reason to make any rushed decisions unless someone is having a problem with aspirin.

So you if you are already on aspirin and doing fine on it, and your next appointment to see your doctor will be within 9 months or so, I suggest considering not even asking your doctor until your next appointment. That gives time for the final report to be published, and time for your doctor to consider the information. That’s better than making a decision based on a headline.

More COVID-19 Coronavirus Thoughts

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Christian IV’s crown in Rosenborg Castle in Copenhagen, Denmark.

Social distancing is strange when it hits home. The last time we had kids and grandkids over for dinner, about a month ago, we tended to hold back giving the usual hugs. Three people were in the medical profession and two lived 5 miles away from the nursing home in Kirkland that had the big outbreak. It was like an Agatha Christie whodunnit murder mystery and we were all suspects!

At work we’ve been careful to conserve supplies for quite a while, particularly to help out for the places that really need them.

When wearing a gown I couldn’t swipe my badge to log in and out of the computer as my badge was under the gown (if over then it risked touching the patient if I was examining them). I had to pull the reader to me. Face ID doesn’t work with a mask. Last month I saw a new patient, who happened to have a cold, so we both wore masks. Neither of us really saw what the other looked like. More recently most everyone wears masks.

I often check a patient’s throat when doing a routine exam, but would skip it if not really needed to avoid having to be relatively close while they may be actively exhaling in front of me. When I do a physical exam on men, I’d think twice about telling them to turn their head and cough!

We’ve quickly changed how we practice medicine. We try to screen patients to prevent potentially sick patients from coming in. It doesn’t always work. They may have already had an appointment to follow up on their diabetes, and not mentioned that they had a cough. A phone screener may have asked if they went to South Korea or Italy or had known exposure, but that doesn’t mean they didn’t have exposure to someone sick that has yet to be diagnosed, and more recently travel history no longer matters. I documented any personal protective equipment (PPE) I used (mask, mask with eye shield, gloves, gown). That way if I later find out my patient was infected, I could look at what protection I wore. Because of equipment shortages I could not wear everything for every patient I see.

I purchased scrubs for the first time a few weeks ago. When I worked in the hospital many years ago, they provided them to us. Working in the clinic it was not considered acceptable attire for doctors. Because of the pandemic, administration authorized us to wear them. When I would get home, they would go straight to the washing machine, and I would head to the shower as a decontamination routine. We never made so much use of our LG Sidekick pedestal washer!

We’re heading towards doing telemedicine in a much bigger way. That protects our patients from being exposed coming in, and it protects health care workers, and other patients, from being exposed to sick patients. Various legal restrictions and how we are reimbursed has limited this, but now the government as temporarily removed many

restrictions and the government and private insurances are starting to pay for virtual healthcare. I was 17 minutes late the first time I did a case by phone. I was waiting for my nurse to check her in before I realized that I was supposed to call her! I also quickly realized that I needed to use my speaker phone as I could not type efficiently holding the phone with one hand. I’m now set up to do video visits from work or home, but it has been a challenge for many patients. The easiest way is to use a smart phone (iPhone or Android) and download the Epic MyChart app as we use Epic as our electronic medical record
(EMR). Then we can connect on our end using the Haiku app and have a secure video conference call. But some patients don’t have smart phones, and for those that do they often don’t understand that they need to download the app, and that there are a few steps they have to do on their end to actually connect. Some try to connect through MyChart on a browser, but that often doesn’t work. A couple of people couldn’t download the app because they didn’t remember their password for the app store. Another video app we’ve used, that is preferred by our legal department, is less intuitive and I’ve only been successful with it a few times. Occasionally we run into bandwidth issues and sound or video quality is not good. I’m not sure where the problem is, but I suspect it’s on the patient end as I’m connecting to a fast internet and Wi-Fi. When it works, though, it’s generally a good experience for patients and myself. Patients can show me a rash or swollen ankle. For both sides of a video conference, it’s helpful to have a good light source from the front. If it’s from the back one’s face is in the shadows. Try just using the rearview camera to get an idea of what you’ll look like (and what’s behind you!) beforehand. Although I think visits in person tend to be best, it’s certainly safer doing it virtually. Patients appreciate that, as well as the convenience.

People generally know that this pandemic has been hard on healthcare workers. What many people probably don’t realize is that in a healthcare organization a lot of others play important supporting rolls. As I serve on an informatics committee and am a Physician Builder, I’ve had a chance to see some of what’s going on. To place an order for a brand- new test, for example, some analyst had to build the functionality into our electronic medical record. There are many new workflows that were needed, including for telemedicine, and in the beginning the analysts were told we needed them yesterday.

Once a week I work with a family medicine resident to teach them geriatric medicine. I spoke with one last month that I wasn’t sure what was going to happen with her rotation since both I and my colleague were moving towards stopping seeing patients in the clinic. After she spoke with one of the faculty, they suggested she observe me doing telemedicine as I have a reputation for being good with computers. But how could I have her watch yet keep the recommended 6 feet of social distance? I did a test where I chatted with her over one of the apps and I was able to share the screen but then she went on vacation. I’m still trying to figure out a way that I can have a resident remotely do a video chat with the patient and myself. Not all the software we are using allows group video chats. Plus, I want it to be meaningful education for the residents.

I think this experience has brought increased camaraderie among doctors and others in healthcare, like serving together during war. Fortunately we have had less cases than expected in Washington so far, and we’ve not faced dire circumstances in my clinic.

Although it’s unpleasant to consider, on the plus side, this has finally got me to stop procrastinating and pushed me to get my estate plan and medical directive done.

Aspirin – Questioning Established Wisdom

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Bayer began selling aspirin (acetylsalicylic acid) in 1899, and the similar salicylic acid, derived from willow bark and other sources, has been used medicinally for thousands of years.  Since the 1960’s it has often been used for heart attacks and strokes. Studies showed that in patients who have had heart attacks, daily aspirin prevents another one. This is know as secondary prevention.

Doctors have assumed that it would also be good to prevent the first heart attack in patients at higher risk. This is know as primary prevention. The problem is that’s much harder to prove.  Even patients at higher risk might never have one, or maybe not for many years, so a research study can take many thousands of patients followed for many years, thus costing many millions of dollars, to tell if there is a benefit. Rare side effects can take many years to figure out. There have been studies done over the years, with inconclusive and sometimes with inconsistent results.

According to a trio of recent articles (Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly, Effect of Aspirin on All-Cause Mortality in the Healthy Elderly, and Effect of Aspirin on Disability-free Survival in the Healthy Elderly), aspirin use may cause more harm than benefit for primary prevention. They looked at patients >= 70-year-old (>= 65-year-old for blacks/hispanics in the US). A low proportion of participants regularly took low-dose aspirin before entering the trial, which did not directly address whether healthy older persons who have been using aspirin for primary prevention should continue or discontinue its use. Now 2019 guidelines from the American College of Cardiology and the American Heart Association recommend low dose aspirin for primary prevention only in limited patient populations at higher risk.

When it comes to medical treatments, it’s pretty much always a question of balancing benefit versus risk and cost. For aspirin, cost is pretty much not an issue. Although studies may look at thousands of patients, people are not homogenous, and any particular study may not apply to a particular patient. The guidelines listed above state that aspirin might be considered for primary prevention in adults age 40 to 70 at higher heart risk but who do not have a higher bleeding risk. They do not recommend it for routine use for those over 70-years-old. Note that it still may be warranted in some because of higher risk, and it’s still recommended for most older patient if they have known heart disease.

I think these new recommendations will eventually lead to less patients taking aspirin to prevent a first heart attack. This will lead to less bleeding, but it may increase other problems For example, aspirin may decrease the risk of colon and other cancers. It may help prevent deep venous thrombosis (DVT) blood clots in the legs, which could lead to a more serious pulmonary embolism (PE), so long distance air travelers may be at higher risk of a clot if they stop taking their aspirin. They could just take it before a trip, but will they remember? The FDA just added a block box warning for Uloric (febuxostat), a medicine used for gout, because of recently appreciated increased risk of cardiovascular disease. Surely there will be patients on that medication on aspirin for primary prevention who will stop aspirin, as a result of reading in the media that they should, but will then go on to have a heart attack because either they didn’t discuss it with their physician, or they did but their doctor didn’t know or appreciate the increased heart attack risk with Uloric. That medicine, by the way, should also be judged on benefits versus risks and alternatives, and is still appropriate for some patients, though not as many people as the drug reps would have had doctors believe. They’ve stopped promoting it as it’s almost generic, but that’s another story.

Trying to Destroy Healthcare the Ostrich Way

Copyright: <a href='https://www.123rf.com/profile_andreykuzmin'>andreykuzmin / 123RF Stock Photo</a>Ostriches reportedly stick their heads in a hole if they see something they fear. If they can’t see it, then it must have gone away. President Trump, with most republicans lawmakers going along, is trying that same tactic on the public. Despite 7 years of promises, and multiple attempts, Republicans have been unsuccessful overturning the Affordable Care Act, otherwise know as ObamaCare. So Trump has been doing everything he can to destroy it, with the hopes that it will wither and die, then he can blame Democrats on it’s demise, claiming it was bad legislation. This despite not having a good alternative.

One of the efforts have been to keep people from signing up for coverage for next year. The Trump administration has cut the advertising budget by 90%, shortened the enrollment window, and will close the site on some Sundays for, “maintenance.” They figure that if people can’t see it, they will think it must not be there.

Well sign up just started. If you don’t otherwise have coverage, such as through work, sign up right away, while you still can.  You must sign up by 12/15/17. Don’t wait until the last minute as you might not be able to get on the site. Don’t be scared off by reports of premiums going up. Although true, subsidies also go up per the law, and it costs nothing to find out what it would cost for coverage. Go to healthcare.gov.

Regulators Asleep at the Wheel

Recently the Federal Railroad Administration and Federal Motor Carrier Safety Administration said they would no longer continue pursuing regulations requiring testing for sleep apnea in truck drivers and train engineers.

Sleep apnea is a condition where, in the most common form, the airway is partially blocked during sleep. This leads to daytime sleepiness, increasing the risk of accidents, plus is otherwise hazardous to patient’s health if untreated.  The National Transportation Board determined that a 2013 train derailment that killed 4 and injured 59 was a result of undiagnosed sleep apnea. According to the railroad Metro-North in the New York City suburbs, 11.6% of it’s train engineers have sleep apnea.

Screening involves an overnight sleep test.  We require our pilots to get tests for drug use. Why would we not want to test truck drivers and train engineers for a common problem that is just as dangerous? It’s part of President Donald Trump’s campaign to cut federal regulations. Although some regulations are excessive, this is not one of them. What’s next, repealing seat belt and motorcycle helmet laws?

Politicians Playing Doctor

Recently the British baby Charlie Gard has been in the news. Unfortunately he was born with a rare disorder called Infantile Onset Encephalomyopathic Mitochondrial DNA Depletion Syndrome. The parents of the 11-month-old boy have been in a court battle with the London Hospital caring for him since October. The hospital obtained a court order to remove the boy from life support as the doctors treating him said his condition was terminal and that treatment would just cause the boy additional distress.

The parents have held up hope for an experimental treatment with nucleosides a U.S. doctor has offered, even though he had not examined the patient. In fact no person or animal with Charlie’s condition had ever received the treatment. Reportedly 9 patients with a related disease had some improvement with the treatment.

President Trump weighed in:

Recently Republican House Congressmen Brad Wenstrup (Ohio) and Trent Franks (Arizona) said they would introduce a bill to give Charlie permanent residency in the United States so he can travel for the experimental therapy.

I sympathize with the parents. It’s awful to see your children with serious illness. However sometimes stopping care really is the best thing to do. The US doctor reportedly said a 10% improvement in strength was possible. But that’s the same as saying you can go from lifting 10 lbs to being able to lift 11 lbs. It’s just not going to make a significant difference.

I also believe in research studies. In fact close to 20 years ago I had a patient with a different neurological disorder who could not be removed from a ventilator. I received FDA approval to administer an experimental treatment. It may have helped – they did get off the ventilator, but they died not that much later. That drug had preliminary treatments in animals, then in humans.

If our politicians were really that concerned about the health of an infant in another country, maybe they would accept refugees from countries such as Syria, where innocent people have been in terrible conditions. Their chances of improvement would practically be guaranteed. Unfortunately for Charlie, that’s just not realistic.

Exploring Cuba – Part 2

In my prior post, I discussed a trip I made to Cuba in December. In this second part I will focus on some medical aspects.

When my patients ask about foreign travel where there may be health concerns, I usually direct them to the CDC site. It’s also where I go to check for my own travel, though I look at the more detailed Clinician view.  To start off it recommends typhoid vaccination.  You have a choice of the oral or injected. The oral is a live virus that is taken every other day for 4 doses, starting 12 days before potential exposure. It gives better immunity, but should not be taken by people with a suppressed immune system, such as those on steroids. The injected form is a non-live vaccine, a single injection taken at least 2 weeks before potential exposure. The injected form is harder to find, and even pharmacies that carry it may need to order it in advance. The injection is more expensive, and neither vaccine is usually covered by one’s health insurance. There are other vaccines recommended, but typhoid was the only one I needed.

Cuba has mosquitoes that may carry Dengue Fever, and more recently Zika. I chose to travel in December because it was outside hurricane season, it was the cooler time of the year, and there are less mosquitoes around that time. Cuba does a better job than many other countries controlling mosquitoes, but I was still cautious. Due to the cost, they don’t use insecticides to fumigate buildings, but rather burn oil, as can be seen in the photo above. We checked in to one place not long after they had done their weekly spray, and had to wait 30 minutes for smoke to stop poring out the window! I sprayed much of our clothes with permethrin spray, and applied DEET to exposed skin, especially in the evening when the mosquitoes are more apt to bite.  I texted PLAN to 855-255-5606 to get periodic updates from the CDC about Zika before the trip.

Food is generally safe to eat, but we avoided street food. The tap water is not safe, however. We mostly depended on bottled water and avoided ice except at a few restaurants and bars that filtered their own water. Bottled water is kind of pricey at times. The best deals are on large (3-4 liter bottles) that you can find sometimes in stores. They often cost the same price or less than a one liter bottle that is more readily found. I also brought along a SteriPEN which sterilizes water with ultraviolet light. I didn’t have enough experience to trust it completely to replace buying bottled water, but used it to sterilize water to rinse our toothbrushes, and would have used it if we didn’t have bottled water. I also recommend bringing Imodium, and an antibiotic from your physician for traveler’s diarrhea. I’d also bring some toilet paper. Many public toilets often didn’t have any, or  you’d get a small amount from an attendant after giving a tip.

Bring sunscreen. It’s not easy to find places that sell it in Cuba, and it’s expensive.

Months before my trip I tried to arrange to visit a hospital. It so happened that the fiancée of a Cuban in the travel industry who helped with some of the arrangements was an anesthesiology resident. He told me that he would love to show me his hospital, but that unfortunately the government required a 30-50 dollar payment, despite the fact that I said I would be bringing some medical supplies. He also said I would not be allowed to tour the medical school due to, “national security!” After I arrived we talked a number of times, and ultimately he could not get government approval for me to see his hospital, even though he said everyone at the hospital wanted me to come. He said the only exceptions they made were for those with an educational visa, coming to teach basically, and even then they needed at least 3 months notice.

Although I could not tour the hospital, I had some long conversations with that doctor and learned a lot about their system. All things considered, the Cuban doctors are apparently pretty good, but they are particularly hampered by old equipment and lack of medications and supplies. The anesthesiology resident showed me photos of anesthesia equipment they currently use that are from the 1980’s. He said they don’t have air scrubbers in the operating rooms, so sometimes everyone gets sleepy!  He told me about a colleague of his who was working with a nurse anesthetist. She let her go home early because she wasn’t feeling well. Later she had to intubate a pregnant patient. Unfortunately it didn’t go well and the patient suffered brain damage. During a subsequent investigation the government argued that had she not let the nurse anesthetist go home early, maybe the patient wouldn’t have died because she would have had additional help. She was sentenced to 12-15 years in prison, and even if she gets out after 5-7 years for good behavior, she won’t be allowed to be a doctor anymore! Because physicians are held responsible for a bad outcome, Jehovah’s Witness patients are told they can’t refuse blood if needed, though they do take measures to minimize the need. Doctors are paid poorly (the resident said after he finished he would make 80 CUC (about $80) a month), often less than taxi drivers. It’s very difficult for specialists to be allowed to leave the country, even on vacation, for fear they won’t come back. If they go on medical missions they are paid better than usual, but they only pay them the bare minimum while they are abroad to encourage them to return home after the mission. I was surprised to learn that they are fairly tolerant in terms of LBGT, in part due to Raúl Castro’s daughter, and they even have doctors who do sex reassignment surgery to change gender.

Many Cubans rely on natural formulations, such as herbs, they call ‘green medicine,’ due to cost or personal preference. The anesthesiologist told me that for a man to get a prescription for Viagra (sildenafil) he has to see his primary care doctor, a urologist, and a psychiatrist. Once they get a prescription, though, they are basically assured of getting it indefinitely. He said many patients research their condition and tell their doctors what prescription they want, and they often comply.

One of the most dangerous things in Cuba are the cars. They are famed for their old cars, many of which look fabulous, but they lack safety features, such as seat belts and airbags. In fact we were in a car accident. We hired a car and driver for 6 days through a contact in the travel industry in Havana. He was probably around 60-years-old, and reportedly one of their best drivers. He was very nice, funny, and knowledgeable, and arrived to pick us up in a pretty new Chinese car, a BYD (Build Your Dream). On the first day as we were driving, while my wife and daughter were sleeping in the back, the car started drifting to the left. I grabbed the steering wheel, noting the driver had fallen asleep. He quickly awakened, pulled the car to the side of the road, and got out to stretch. He came back in and apologized, saying he had gotten up early to pick the car up. The next day he said that actually he hadn’t slept well because he had witnessed a teenager, who was not paying attention listening to music, hit by a car the day before.

In the middle of the car trip I met with the doctor I mentioned above and told him about the incident. I wondered if he might have sleep apnea, though the driver had said he had never had such a problem.  He said that they don’t test for sleep apnea because they don’t have CPAP machines to treat it.

The rest of the road trip went fine until the final day. Once again my wife and daughter were sleeping in the backseat when the driver fell asleep again. This time he swerved too quickly for me to reach the wheel. We hit a guard rail, damaging the front end and side mirror and puncturing two tires. The driver said he did not know why he fell asleep and that he had been well rested. One theory I came up with is the possibility of carbon monoxide poisoning from a leak in the exhaust system. Our driver obtained another car and driver for us, who brought us back to Havana.

No one was serious injured, but my wife was seated behind the driver and her left elbow hurt immediately afterward. Back in Havana we went to a clinic that caters to foreign visitors. X-rays showed no fracture.  She was given a skinny piece of gauze to use for an arm sling (she had been using my belt up until that point). When it came time to leave they said we owed 100 CUC (about $100).

Boarding Pass

 

Cuba requires one to have medical insurance to visit the country, and they add $25 to the price of each airline ticket to cover it. Delta Airlines said to show the boarding pass if needed as proof of insurance. I showed the boarding pass, but they said it wasn’t good because it said AeroMexico on the top. I pointed out that below that is said that it was operated by Delta Airlines. They said they would have to investigate it. They gave no indication how long it would take, and given that it was the evening I didn’t think they would get an answer that night. I eventually gave up, paying the money so we could get her passport back and leave. I wrote Delta Airlines and explained the situation, sending them copies of the boarding pass and the medical bill. We were on something like their 4th commercial flight to Cuba, so I figured they would be eager to work out any glitches. I was wrong. Besides some email exchanges, they called twice at 7 am. When I pointed out the early hour I was told it was 10 am on the East coast. You would think an international airlines understood the concept of time zones! In any case, ultimately I was told we, “..must request a refund of the insurance premium directly with the Cuban insurance provider.” Really? They expect their customers to request a refund from the Cuban government?! All I was asking for was the approximately $100 I paid for the clinic. Not the taxi ride there and back, the medical costs after we got home, to say nothing of pain and suffering. Imagine someone of lesser means ended up needing much more care and being told the insurance they thought covered them didn’t. That might keep people from choosing to visit Cuba, at least on Delta Airlines.

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