An Appendicitis at Nevis
25 February 2011 | Charlestown, Nevis
H. Veisz
We left Antigua's Falmouth Harbor on January 5 with fresh provisions, an ambitious cruising plan, and a ticking time bomb. Lorraine had already felt sharp abdominal pains during our last full day in Antigua, but not enough to deter her from walking the four mile round trip from the Catamaran Marina to the customs office at Nelson's Dockyard, to seek medical help, or to delay our departure plan. To the contrary, she was determined to move on, and so we did.
A night at anchor in Five Island Harbor, on the west coast of Antigua, passed pleasantly. Indeed, we thoroughly enjoyed the fine surroundings, and the fact that we shared the large harbor with only three other yachts -- a nice contrast to the crowded harbor at Falmouth. Lorraine felt better. Nevis beckoned, only 48 miles away. And so we sailed on.
Nevis is a very small island, an oval about five miles from east to west, and seven miles from north to south. There is no protected harbor, but the Nevis Port Authority has installed 100 moorings on the leeward side of the island, along Pinney's Beach. The moorings stretch from Charlestown (Nevis' principal town) to Sunshine's (Nevis' principal beach bar). Use of the moorings is mandatory, but availability is not a problem. When we arrived about 97 of the 100 moorings were inexplicably vacant.
Lorraine's abdominal pain was largely forgotten as we enjoyed a fast downwind sail to Nevis, rounded its southern end, and continued to the mooring field. The wind was blowing strongly as we approached the moorings. Lorraine, now at the wheel, struggled to hold us alongside a mooring while I threaded two lines through a small metal loop atop the mooring ball. The first attempt failed. We secured the boat on the second pass.
We finished at 17:00, too late to report to customs, just right for mixing rum punch and watching the sunset. The view was splendid: to the east the long line of Pinney's Beach, backed by palm trees, stretched in both directions; across a narrow channel to the north St. Kitts was clearly visible, its shoreline curving to the northwest; elsewhere there was only water and the setting sun. Nothing seemed very much amiss. Just a bit of tenderness.
The next morning we took our dinghy to a dock at the heart of Charlestown's waterfront. It was Sunday, and quiet. A taxi driver, John, greeted us at the dock and offered some useful information. Our destinations (the port authority office, customs and the immigration office) were too close to use his services -- a fact that did not diminish his good cheer. As we walked through town the only activity was in the churches, where filled pews could be seen through open doors.
Our last stop was the immigration office, located at the police station. While the officer was examining our passports with an intensity suitable for a terrorism suspect, we struck up a conversation with a couple from Sailacious, another American sloop, who were awaiting similar scrutiny. We planned to rendezvouz with them later that day at Sunshine's.
Symptoms began to accumulate. Lorraine uncharacteristically stated that she would like to return to Aponivi to rest. Tenderness in her lower right abdomen increased. She opted to stay behind when I took the short dinghy ride to Sunshine's. I left with a handheld VHF in case Lorraine needed to radio for assistance. The call came quickly -- about half way through my first "Killer Bee", Sunshine's signature drink. With the help of our new "Sailacious" friends I pushed the dinghy off the sand and sped back to Lorraine.
By this time, Lorraine had added a fever to her list of symptoms, and was starting to think appendicitis among a list of other possibilities. (Classic appendicitis symptoms include four to six hours of dull abdominal pain, followed by sharp pain in the lower right abdomin, and a low grade fever of 99 to 102 degrees -- all in rapid succession. Lorraine had sharp but short-lived pain in Antigua, followed five days later by lower right quadrant tenderness and fever, an atypical progression that clouded the diagnosis.) As a retired nurse her concern about a possible appendicitis carried great weight. It also caused considerable anxiety, knowing that a ruptured or perforated appendix -- one possible ending -- could spread infection throughout the abdominal cavity. If that happened, as it often does when medical care is delayed, it could prove fatal.
We got into the dinghy, sped back to Charlestown, and taxied to the island's one medical facility, the small Alexandra Hospital. Lorraine was whisked into the emergency room and a surgeon was summoned from elsewhere on the island. An IV was set up. And then we waited and contemplated our surroundings. Some of the furnishings in the room had more rust than I would like to see. I began to wonder whether the surgeon's skills (we had not yet met him) might be a little rusty too. I vividly recalled a former partner's advice that we purchase med-evac insurance before we set sail and, not knowing what was in store, I wished I had done so.
This was a part of Caribbean life that we had not seen before, and that we had not really thought about. The hospital reflected the differences that we had come to know between the Caribbean and the United States, and tended to magnify them. The island could not afford all of the sophisticated equipment that would be standard in a US hospital, but what it did have was offered generously. Nobody asked what insurance we had, only what help we needed.
When we were billed for anything, it was in the same small amounts that islanders were asked to pay; it made no difference that we had a yacht moored in the harbor. (A donation will be made.) The nurses were very caring, and very competent.
The surgeon arrived, clad in a red t-shirt, shorts and sandals. He conducted a conscientious examination, feeling for abnormalities and using an ultra-sound device that was in the ER for an inside look. The literature says that "diagnosing an appendicitis can be tricky". Symptoms are "frequently vague or extremely similar to other ailments", some of which have the sound of doom. Lorraine's case was particularly difficult to diagnose.
In a few percent of appendix cases -- including Lorraine's -- a strong immune response causes the tissue surrounding the appendix to swell so much that it walls off the appendix and prevents infectious material from spreading. The reaction can be life-saving, but it also makes an appendicitis harder to detect, and significantly complicates the surgery if an appendectomy is begun.
Based on what Lorraine told the surgeon about the slow progression of her symptoms, what he had felt, and what he had seen on the ultra-sound, he tended to discount the appendicitis theory. (Two doctors in New York did the same, before ordering a CT Scan that dispositively revealed an appendicitis.) One of the dread alternatives entered the conversation, and that possibility lingered in our minds overnight.
The next morning, following his instructions, we returned for a more sophisticated ultrasound. The dread alternative was ruled out. The actual problem remained elusive. Two powerful antibiotics were prescribed and provided -- a precaution that may have made all the difference. We were given the green light to fly home for further diagnostic tests and treatment.
The few taxi drivers who wait at the Charlestown dinghy dock are a font of information and a source of encouragement. The Sailacious crew came asking about us and were told by a driver that we were at the hospital. As we walked past the group to our dinghy, one driver (the "Music Man") assured us that "Nevis was a blessed island" and that Lorraine was "already healed". Nevertheless, we began to tackle the logistics of getting Lorraine to a New York hospital, and getting Aponivi back to the safe haven that only Antigua could provide.
We secured next day flights from St. Kitts to Miami and from Miami to New York. The small Port Zante marina at St. Kitts had a slip available, and we departed for it at once. As part of a two person crew, a doctor's note could not get Lorraine a day off, and she performed without complaint when it was time to hoist the dinghy on deck, and rope the piings at Port Zante.
A chance comment a few days before we left Falmout Harbor provided all of the information I needed to meet our longer term boat needs. Stan at Antigua Rigging (as fine an outfit as can be found anywhere) mentioned that a customer had just suffered a medical emergency on board, and that he had dispatched a crew to retrieve their boat. I described our predicament to Stan over the telephone, and he took it from there. At his direction, a local yacht agent met us at St. Kitts to handle customs and immigration matters, and a highly proffessional crew arrived at 07:00 the next morning to sail the boat back to Falmouth Harbor. The yacht agent, Rickie, returned at the same time to handle the departure formalities. Then, before we parted, he asked if he could take our hands and say a prayer for Lorraine. His prayer, and his genuine concern, warmed our hearts.
We then headed to the airport. Up north, a record breaking blizzard was heading toward New York, shutting airports all along its route.
We arrived at the St. Kitts airport with a well justified sense of urgency. We had been lucky so far, but we knew we were pressing our luck if it was an appendicitis. The storm delayed the aircraft's arrival by three hours and we began to anticipate a night at Miami. That turned out to be overly optimistic. The flight crew determined that another leg would put them over the maximum number of hours they could fly in a day, and our depature was put off until 06:00 the next morning. The Airline put everyone up for the night at a Marriot resort, which would have been a splendid experience under other circumstances.
By the time we left St. Kitts, the storm had reached the northeast, closing airports from Washington to Boston. We approached Miami not knowing when we could take off again, but thankful that a major hospital would be within taxi range if it was needed. As we began to take comfort in that thought the pilot announced that we were "experiencing engine problems", that he had "declared an emergency", and that emergency vehicles would be on the field when we arrived. We were sitting in an emergency exit row, and I took renewed interest in the instuctions for using it. There was no need. The engines kept turning. Our decent seemd normal. But the fleet of fire engines deployed near the runway, and the absence of other aircraft from the vicinity, suggested that there had been some doubt about the outcome.
The next morning, in New York, diagnostic work continued, and ended with a CT Scan that was not available in Nevis. Lorraine was sent to the emergency room with the expectation that she would be operated on immediately. The surgeon steered a different course. When treatment is delayed to that extent, and the patient has been fortunate enough to have been saved by a defensive "wall" of surrounding tissue (a phlegmon in medical parlance), the potential complications of immediate surgery outweigh the benefits. Things are not where they belong. Mistakes can be made. The preferred course is a ratcheting up of what the doctor on Nevis had begun: three days of in-patient antibiotics, followed by a week of antibiotics in close proximity to the hospital, followed six to eight weeks later by appendectomy.
We are between the antibiotics and the appendectomy, closer to the latter. Lorraine is doing well. Apponivi, Antigua Rigging assures us, is doing well. By mid-March I expect to be underway again on Apponivi, heading back through Nevis, the Virgin Islands, the Turks and Caicos, and the Bahamas, to Charleston and my temporarily beached mate. From then on, we sail together again.