Changes at the Clinic

One thing about living here, you come to expect changes.  And sure enough, the procedures at the clinic (EBAIS) have changed again :-). 

I had gone to my clinic in May for my regular blood tests, and had been putting off going back to find out the results.  Mainly, because I am (still) not a morning person, and any trip to the EBAIS means leaving the house by about 6 a.m.  Honestly, who can even think that early in the day?!?  Well, I made it this morning (sorta - I didn't actually leave the house until quarter after 6).  I got there after the crowd had already gotten their numbers (they open the doors at 6:30), but they hadn't run out of spaces.

About a year ago, they shut down a neighboring clinic, and so my clinic absorbed all those patients.  They modified the procedures then to have two sets of numbers - when you first came into the clinic, you would grab a number (from the right stack), then wait for them to call it.  Then you showed your carnet (like an insurance card) and ID, and got an assigned time for your appointment later in the morning.  This was sometimes enough time to go back home, go get some breakfast, or just sit there and read or chat with your neighbors.  When it was time for your appointment, the nurse would call your name, take down your information, take your weight, blood pressure, etc., then send you to the doctor.  On your way out, you dropped off your records, got any prescription slips or follow-up appointments, and you were done!

Now (don't ask me why), the procedures have changed again.  You no longer get an appointment time - everyone gets "7:00 a.m." (even if your number comes up after 7).  And, everyone first sees the nurse, then goes back out and waits for another call to see the doctor.  The effect of this is (1) a lot of confusion (2) irritable clinic office workers and (3) missed reading opportunities (the latter is especially tragic!).

My first hint of confusion was when people kept going back to the office window.  Then, when it was my turn, I fully expected "the usual" - I would present my carnet, and get an appointment.  But the clerk asked if I *had* an appointment for 7 a.m.  I thought "huh? it's after 7, and I'm here to *get* an appointment!"  And, of course, I had no clue what to actually say to her.  Finally, people took pity on me - another patient explained, and another clerk made my appointment (for 7 - LOL).  Everyone kept saying they would call me soon (and they did, but I suspect they were awfully tired of saying that to everyone).  Several of the times that I was waiting to be called, I sat next to a lovely lady who was a retired English teacher.  She said that *everyone* is confused by the new system.  And proof came soon enough - she didn't hear her number called, and so missed her place in line, and had to get a new number, waiting even longer.  There was not a single time while waiting that you could relax and simply wait without listening with great anxiety for either your number or your name.

All told, people now "wait" 5 times:
- wait in line for the door to open (the only time it is safe to read)
- wait for your number to be called
- wait for your name to be called to see the nurse
- wait to see the doctor
- wait to get your prescription slip or follow-up appointment

Ultimately, I was done by 8 a.m., so I really don't know if this new system is faster per patient, or if I just got lucky. 

But the good news?  All my test results are *great!*

Phew! Not Dengue!

I do not have Dengue!

We had a little scare here this last week - I got sick on Thursday, and by Saturday morning, I had all the classic symptoms of Dengue Fever.  Fortunately, ALL in miniature, so not a whole lot of pain or life-derangement :-).  I felt well enough to go to class Saturday, although I was not really with it (but no tests, so lucky me!).

By Monday, we had decided that I'd better see a doctor to find out if it really was Dengue.  We had read that not everyone has the severe symptoms, so even though mine were minimal and very short, it was still possible.  The most important reason to know for sure whether or not I had it, is that the second time someone is exposed to the virus, it can be life-threatening.  Dengue Hemorrhagic Fever is a high risk when someone has the dengue antibodies from a previous bout. 

Well, it turns out that the EBAIS is closed on national holidays* (imagine that!), and Monday was Juan SantaMaria Day.  We made our trek to the clinic, not really expecting it to be open, but we didn't know for sure (now we do!).  We couldn't go Tuesday, so that left today.  By the way, each trip to the EBAIS means getting in line somewhere around 6:00 a.m., getting an appointment for later that morning, perhaps returning for tests, etc.  Basically, you get up too darned early, and your day is shot.  But, you get pretty much everything taken care of all in one day.  Today was only slightly different, because dengue is a public health issue, and so the blood test for it is "urgent."  So, after my morning doctor's appointment, we went to the urgent laboratory at UCR, got blood drawn, then went to the cafeteria there for brunch.  We returned to the clinic for the results.  We had a little language mix-up**, and so were two hours late :-| but they fit us in!  And... NO DENGUE!  Turned out it was a bigger relief than I anticipated!  I'll still worry a bit about mosquito bites, but if the bugger is carrying dengue, at least I am back at square one in that progression.  Square one is a *good* thing sometimes!


* In case you didn't know, next week is Semana Santa, and Thursday and Friday are national holidays too.

** language mix-ups are no fun!  And here's an easy one:  12:30 sounds like "dosayeemedia" and 2:30 sounds like "doseemedia"  - say that fast and see what happens...  The fix is this - write down the numbers and confirm those with the person giving you the appointment.  It's a bit harder to *remember* to do this...

Public Health Care - Ebais Clinic

I picked up some germ or other last week, and finally had occasion to visit my local public health clinic. These small doctor offices are called "Ebais" - the one you go to is determined by where you live. Ours happens to be just a block and a half away :-). Strange as it seems to gringos, everything at the Ebais is free (that is, it is 100% covered under the CCSS public insurance).

To see a doctor, here's what you have to do:

1) make sure you are affiliated. When you first move into your new home, find the local Ebais and register. You take your CCSS receipt (and your last CCSS card, if you have one), and your cédula. If you are a family covered under one receipt, you need to go together and take all relevant certificates (marriage, birth); these have to be "recent" copies (The definition of "recent" varies from less than 3 months to less than 6 months. Don't ask me why a birth certificate has to be recent.). Our Ebais only did affiliations between 8:30-12:30 and 1 and 2, Monday through Thursday. When you register, you get a new card and (maybe) an appointment booklet. You are encouraged to "plasticize" your card (there are street-side vendors who do this). This CCSS card is also called the "Carné del Ebais."

2) make an appointment. Go to your Ebais at about 6:00 a.m. and wait in line. This morning, we got there at 6:15, and there were 25 people ahead of us. The doors open a bit before 6:30, everyone files in and takes a number. When you number is called, you go to the window and show your CCSS card, appointment card, receipt, and cédula. You get an appointment for later that morning (e.g., 8:45 and 9:45).

3) see your doctor. Take a copy of your medical records to leave with them (you should bring these from your previous doctor). Don't expect anyone to speak English. To make it easier, you will probably want to write out your symptoms in Spanish ahead of time. Pointing and miming also helps. You will see the nurse first, then go back out to the waiting room until the doctor calls you. When you are done with the doctor, you take your file back to the desk and finish up any paperwork.

4) if needed, return for lab tests. Get there at 6:00, wait in line. When they open the doors, go directly to the lab line. A bit before 7:00, the lab opens. It is only open until 8:30. Show your lab request paper, get a number, and wait. If you need a urine test, you have to bring it with you, in your own (clean, dry) container. Jelly jars are common for this :-S.

5) if you need a prescription, return in the afternoon, between 3 (farmacia opens) and 4 (farmacia closes). Bring your prescription receipt to the farmacia window. I like to write down the names from the doctor and check them online before I get them - then I can look up and ask any remaining questions when I pick them up. Sometimes, the doctor prescribes medicine that is not available at the Ebais - when this happens, the doctor tells you, so you know to go to a regular farmacia to buy it (and you get a written prescription for it).

Timing for recent appointments:
- 6:15 in line for appointment
- 7:10 got appointment
- 8:40 return to Ebais
- 8:45 appointment time
- 8:50 see nurse, then doctor almost right away
- 9:40 done with doctor; problem with CCSS card
- 11:00 problem resolved; have new CCSS card
- 3:00 return for prescriptions

- 6:15 in line for appointment
- 7:10 got appointment
- 9:40 return to Ebais
- 9:45 appointment time
- 9:55 see nurse
- 10:30 see doctor
- 10:40 done with doctor
- 10:50 done checking out

Special note: flu shots are available at the Ebais between February 2 and March 31, in time for "winter."

Fixing our Caja – Costa Rican Medical Insurance

One *big* thing we had on our ¨must do¨ list was to fix our Costa Rican medical insurance – the Caja. Rick was fine, but he was still affiliated with the Alajuela clinic (he registered there last year when we lived there). All he had to do was to change the affiliation to San Pedro. But *mine* - ugh! Last year, we didn´t have a recent marriage certificate, and so we couldn´t get my affiliation set up at all! So, this time we came armed :-). We had a marriage certificate, plus we got a copy of our translated and stamped marriage certificate from our residency package (now 3 years old). No problem!

Friday, we walked around asking people where the clinic was, and found it (after it was closed, of course) – it is only a block away!

This morning, we went in and changed Rick´s papers, and got mine started. I have to call after Thursday to find out when to come in and get my card (and this is Christmas week, when you don´t expect to get *anything* done)!

After we have our cards, we can make an appointment to see a doctor – but we have to do that by coming into the clinic at 6:00 a.m - SIX in the MORNING!

December 16, 2008 - Fixed!

Ahhh – today was a day of fixes.

Although the day was not pleasant *at all,* we did get a lot of long-standing items checked off.

We got up early, skipped breakfast, and took two buses to Clínica Bíblica for my surgery follow-up. I got blood tests, an endoscopy, and met with my doctor. All good news! I have a clean bill of health, I can stop taking medication, and have no more restrictions on what I can eat :-).

To top that off, when we got back to the apartment, we found the landlady working away! She was replacing the hot water system *and* the leaky sink faucet! AND I was able to put our water filter on the new faucet! Ahhh, life is good again!

Some costs (with 10% ARCR cash discount):
- complete hemogram = c10,400
- full lipid panel = c18,500
- fasting glucose = c3,600
- TSH = c18,500
- endoscopy = c58,500

Comparing Medical Care for Pain and End-Of-Life

I just saw a report that graded the United States on how we are doing taking care of people when we are seriously ill and dying. There is a whole specialty in medicine for this, called Palliative Care. It focuses on relief of the pain and other symptoms of serious illness.

We are not doing too well. The entire United States earned a "C" and several states completely failed! This got me thinking - how is this graded? and how does it compare to other countries, specifically to Costa Rica?

Well, the grading website (http://www.capc.org/reportcard) references the Journal of Palliative Medicine, which is only available by subscription, so I can't judge the methodology. But the summary of the methodology looks extremely tailored - it excludes small hospitals, facilities for psychiatric treatment, chronic care, rehabilitation, ENT, pediatrics, and federally controlled facilities. What's left? (Setting aside the nature of studies, even ones you could drive a truck through. Maybe that's too harsh? it is a professional journal, after all.) I looked at the results and looked for what I could compare. I came away with the fact that it is difficult enough to find consistency from state to state. There are no numbers or factors I could see that I could use to compare to another country.

So, I looked for a world report (http://www.nhpco.org/files/public/palliativecare/World_map_report_final-0107.pdf), and found one from Help the Hospices and the National Hospice and Palliative Care Organization (NHPCO) from 2006.

This study looks like it is done every year. It categorizes countries around the world by their approach to palliative care.
The four groups are:
1) no known hospice-palliative care activity
2) capacity building activity (but no service yet)
3) countries with localized provision of hospice-palliative care, and
4) countries where hospice and palliative care activities are approaching integration with the wider health system. (defined further at the bottom of this post)

Both the USA and Costa Rica are in Group 4, and so are at the highest level defined. Now, if the USA is not doing too well, but it is at the highest level, it is clear that the world as a whole has a long row to hoe.

Here is a brief history of palliative care for each country:

In the USA, the Connecticut Hospice provided the first home care service for the dying in 1974. The forerunner of the National Hospice and Palliative care organization (NHPCO) was founded in 1978. Reimbursement for hospice patients through the Medicare program was enacted in 1983, and by 2005, NHPCO estimated that 1.2 million patients were being cared for nationwide within hospice programs. To find a report for a specific state: http://www.capc.org/reportcard

Costa Rica is a small country with an established health system committed to providing good quality care at a reasonable price to every citizen. With a government-sponsored network of 29 hospitals and more than 250 clinics throughout the country, the Caja Costarricense de Seguro Social (CCSS) has primary responsibility for providing low cost health services to its 4 million inhabitants. The Clinic for Pain and Palliative Care was established in the Calderón Guardia Hospital in the early 1990s and later became recognized as the National Center for Pain Control and Palliative Care (1999). A national pain control and palliative care policy was adopted in 2001.

The report compares several factors in evaluating the level of the country - Human Development Index, Crude Death Rates, Gross Domestic Product, and Ratio of services to population.

The human development index (HDI) gives a multiple measure of a country’s development, based on: longevity, knowledge, and standard of living. There is a strong association between palliative care and human development, as 83% of Group 4 countries have a high index (1-57), and another 14% with a medium index (58-145).
HDI rank / index:
Costa Rica = 47
USA = 10

2006 Crude Death Rates (CDR) are the total number of deaths per thousand persons which occur in the same year. These ranged from 3.7 to 13.4 among Group 4 countries. The correlation between CDR and palliative care is difficult to state, since the ranges for the groups overlap, and CDR is under-reported. However, the study states that the countries with the lowest CDR in Group 4 are distinctly lower than those in the other groups.
Costa Rica = 3.8
USA = 8.4

Gross domestic product (GDP) per capita is indicative of a country’s wealth; it is the market value of the total final output of goods and services produced in a country over a specific period. There appears to be no relationship between a country’s wealth (GDP per capita) and palliative care development, since high and low income countries are represented in each of the four groups of countries.

The comparison of the ratio of palliative care services to population, and rank in the Americas, shows little difference between the two, especially given the wide range around the world.
Costa Rica (ranked 5th) = 26 services => 166 per 1000
USA (ranked 4th) = 4000 services => 75 per 1000

Studies are interesting in that they try to level the playing field and give an objective look at an issue. These usually involve numbers and statistics. However, the cultural effect, especially on the field of medicine, is stripped. To balance this, think of the differences between a visit to your doctor in the states and to your doctor in Costa Rica. The Costa Rican doctor is trained (culturally and medically) to put you at ease. If you are in pain, you get the pain taken care of, *then* deal with fixing things. Caring for the patient as a person, and showing that you care is a natural part of the Costa Rican medical profession. It seems to me then that palliative care is regarded as just another normal part of medical training. It would seem a little strange to have a specialty just for this. But in the USA culture, where doctors are pushed towards spending less time with patients, and tackling illnesses as an entity separate from the patient, this specialty makes sense. It addresses the built-in lack in treating the patient as a whole in the states.


--- Some more details ---
World Health Organization interviewed Dr. Isaias G. Salas-Herrera, chief of the National Pain and Palliative Care Center, in San Jose, and his assistant Dr. Rigoberto Monestel. They discuss Costa Rica's national policy for pain control and palliative care.
http://whocancerpain.wisc.edu/?q=node/175
The national health policy is here (in Spanish) http://www.ministeriodesalud.go.cr/nornormas.htm
Note that you can enter this URL in Google's translation tool to read it in English: http://translate.google.com

----
Group 4 activities are defined further as:

(breakdown of "Capacity Building" as in Group 2)
• Presence of sensitized personnel
• Expressions of interest with key organizations (eg APCA, HAU, IAHPC, Hospice Information)
• Links established (international) with service providers
• Conference participation
• Visits to hospice-palliative care organizations
• Education and training (visiting teams)
• External training courses undertaken
• Preparation of a strategy for service development
• Lobbying: policymakers/ health ministries

(breakdown of "Localized Activities" as in Group 3)
• Critical mass of activists in one or more locations
• Service established – often linked to home care
• Local awareness/ support
• Sources of funding established (though may be heavily donor dependent and relatively isolated from one another, with little impact on wider health policy)
• Morphine available
• Some training undertaken by the hospice organization

(additional activities specific to Group 4)
• Critical mass of activists countrywide
• Range of providers and service types
• Broad awareness of palliative care
• Measure of integration with mainstream service providers
• Impact on policy
• Established education centers
• Academic links
• Research undertaken
• National Association

Welcome back to California - medical bills!

Welcome back to California - here are your medical bills - yikes!

We had a busy week going to dentists and doctors. I will say right up front, I would not even consider going to any other dentist or doctor in the states - ours are great! However, this is a pure illustration of the differences in the cost of health care between California and Costa Rica.

Cost for a thorough teeth-cleaning, exam, and x-rays:
California = $255
Costa Rica = $90

Cost for a filling - composite:
California = $250 (plus $115 for happy gas and topical numbing, 'cause I'm a baby)
Costa Rica = $50 (as reported by Saratica)

The same week, Rick went to the Doctor for a sinus problem, and came away with three prescriptions for almost $300. We're waiting for the bill from the Doctor, but I am sure it will be over $100. The last time we saw a Doctor in Costa Rica, the office visit was $12.

And people wonder why medical tourism is taking off...

April 4, 2008 - Public Health Insurance (Caja)

We finally decided to sign up for Caja – the Costa Rican public health insurance. This covers you for any pre-existing condition, prescriptions, and emergencies. Everything we’ve heard (though I don’t have personal experience here) says it doesn’t do so well for regular health maintenance – long lines (everyone gets a 10:00 appointment), not-so-full workup (e.g., usually cholesterol is measured, but not HDL/LDL breakdown), and slow timelines for some time-critical procedures (e.g., cancer treatments can be scheduled months too late – I know, yikes!). Many people use a two-tiered method, where they have Caja *and* either private insurance or no insurance but use a private doctor. Since many doctors provide treatment under both Caja and private, you can often use the same doctor for your health – he will be able to tell you when to get something done under Caja.

So, one afternoon we went to ARCR (Association of Residents of Costa Rica) to get signed up. We are already members; this is an additional benefit provided. Normally, premiums for Caja are 13% of your income. But, since we are rentistas, we are not allowed to work. Our residency deposit isn’t really income in the same sense. But ARCR has an arrangement with the government that allows them to cover members under a corporation. So, our paperwork consisted of “getting on the payroll.” I know, this sounds suspicious, but it is legal, and has been for at least a decade. We filled out information, paid three months of premiums, and $5 to activate. Then we got a “payroll” certificate for Rick to take to the Caja office in San José. By this time, it was a bit too late to go there, so we came back to SJ the next day.

We got the Alajuela bus to San José, then caught the cementerio (yellow/orange with purple) bus to Caja (cattycorner from the National Theater). We asked the guard at the entrance where to find the “area administración de planillar,” and stood in a short line. Then we showed the payroll certificate and got a Caja number for Rick. We called ARCR and gave them the number for their records. As of now, we are both covered if we have an emergency. But there is one (only one?) more step.

Since we live in Alajuela, we need to register at the clinic in Alajuela before we can get regular treatment. This is also where we get the insurance cards. The next day, we take a taxi to the new hospital, ask the guard where to go, and he says (arg!) we need to go to the clinic, not the hospital. We take another taxi to Clínica Marcial Rodríguez (which happens to be pretty darned close to our apartment), go to the area marked “afiliación,” show copies of our electric bill and wedding certificate, and Rick gets his insurance card. However, I have a problem. I am supposed to be covered under Rick’s Caja, but the copy of our wedding certificate is not good enough – it is too old (it probably also needs more stamps and translations). Who knew? We have no other proof that we are married – our cedulas don’t indicate this. So we leave with Rick’s coverage secure, and mine a bit iffy – ARCR assures me that if I get in an accident, I will get treatment. We can provide the coverage proof afterwards if needed.

It took three days and a few headaches, but we have coverage! Since we are under 55, our cost is $61 per month. Once we (that is, Rick) reach 55, our cost drops to $43 – nice to look forward to a *drop* in cost!

I’ve since heard of someone who went in to *renew* her Caja insurance, and had a problem with her wedding certificate. Their solution was to get re-married in Costa Rica – it took a couple of hours, 2 witnesses, a lawyer, and $150. We’ve been married over 15 years, and it looks like this might be the answer for us as well. Why not? We already “got married” again in Hawaii – all that was required there was kissing in the wedding grotto…

April 2, 2008 – USA Health Insurance (Rant)

Once in a while, I gotta rant. This time, it’s about how fouled up the health insurance situation is in the states.

Most places that I have worked touted themselves as being on the cutting edge of health insurance reform (I’d say health insurance gimmicks). Most of these changes resulted in the employee paying part of the premium.

When we first heard about this, it was called “Flexible benefits” because you got to choose your health plan, and balance that choice against how much more you would pay each month. This soon became the norm.

Another place I worked pushed even more. At first, they provided you a way to measure your health via a questionnaire. You could do this or not – it was supposedly anonymous (but we suspicious types never really believe that). The next year, you got a discount on your premium if you completed the health questionnaire. The next step was this – if your health measurement indicated you had a problem or a health risk, you got a discount if you did something about it. For example, if you smoked, you got a discount if you joined a stop-smoking program – the discount applied even if the program didn’t work, and you still smoked. Likewise for a weight-loss program. The final step (although there is probably still something that can be squeezed out), was that you only got the discount if the problem got better – you stopped smoking, lost weight, etc. Written this way, you could argue that your health is important to them, and that they are providing incentives for you to get healthier. Cynics would say something a bit different.

If you tie in the insurance changes with the cultural effects of professional life in the Silicon Valley, you get a potent mixture. Life revolves around work. Stress builds up. Health suffers. The attitude is “Oh you’re sick? Did you get that report done?” You see co-workers coming to work with fevers, still working outrageous hours, because they have deadlines and expectations. You get a culture clash when you find out that people in other parts of the company go to their child’s soccer game in the middle of the afternoon (Don’t these people have any sense of priorities!?!?). THEN you find out that you’re expected to join programs to reduce the health problems largely caused by spending so much time at work. And just when are you supposed to go to these programs? So you end up resenting the system and paying more for your health insurance. And you aren’t any healthier…

So, this was just a low-level irritation for me for decades until I asked my health insurer about gastric bypass surgery. Then the irony hit full force. You have health insurance, which you pay more for because of a weight problem. Certainly, you do things like diet and exercise to help it. But there is no way you are going to go to a doctor multiple times per month for three (3) years for a medically supervised program – how can you do this when you don’t even have enough time in the day to get a full night’s sleep? Since retiring, I now had the time and the insurance (18 months of COBRA) to really do something about it. But the insurance won’t cover the surgery unless I have proof of a medically supervised weight-loss program lasting 3 years. This is not what I call encouraging better health. This is more like looking like we care while not paying for surgery.

If you read this, you know that I went ahead with the surgery. I had it done in Costa Rica. It cost about a third of what it would have cost in the states. It cost me about double what I would have paid out of pocket if insurance had kicked in. It didn't - I'm healthier without the insurance.

I realize that my situation is *nothing* compared to so many others. I don’t have cancer, I don’t need a transplant, I don’t need anything experimental. But this is just one more item showing how manipulated we are.

March 11, 2008 – Health Focus in Costa Rica

I’ve just passed my first year of retirement! It’s hard to believe that much time has gone by. One of the main things I wanted to do was to focus more on my health. I have found that my method for most of my life is to focus on one or two things at a time – everything else takes a back seat. I had been spending almost all my effort on work, often without leaving enough time in the day to even get a full night’s sleep (let alone all the other important aspects of life). Well, I was determined to change that. So, I spent the first few months just relaxing; downsizing my stress. We spent a few months in Costa Rica – learned some more Spanish and just lived. Then back to the states to work on our house – worked outside in the yard (and the sun!); definitely spent less time sitting at a desk! Then back to Costa Rica for a few more months. This time, we rented an unfurnished apartment within walking distance of downtown (no car). This meant we walked a *lot*! After 2 months, without thinking too much about it, or trying at all, I lost 20 pounds and knocked the bejeezes out of my blood tests - over 50 points off my cholesterol level, 40 off triglycerides, and almost 20 off glucose levels. Of course, doing the laundry by hand helped, and I can´t entirely discount the effects (beneficial?) of food poisoning…

But I knew from past experience that I could only go so far, and at least a partial rebound was likely in my future – and I also had so much more to fix. So, we took the plunge, and I had gastric bypass surgery in Costa Rica. This is where your digestive tract is re-routed a bit – 90% of your stomach and the first part of your small intestine is bypassed. It makes you eat less, and digest more of your food lower, so you absorb fewer calories (and vitamins). It also means you have to let your stomach re-learn how to handle food – it has been about a month, and I finally get to try solid, near-normal food.

Rick was uneasy with the idea of my having surgery – let´s face it, it is a serious undertaking. But then he thought about this – our bodies have evolved to be efficient, and to store fat for the times when we need more fuel than we can take in. In these times, that is just not very often… So, if your body is not working the way you need it to, there is nothing wrong with changing your body. It´s still a bit scary, of course…

The long-term effects for most people is that you lose 80% of the excess weight. Some people gain some back, but not all of it. This is a permanent change, and basically forces a change to your eating habits. The other options for bariatric surgery were either not permanent, or were not as positive.

In the short-term, most of the excess weight is lost in the first 6 months. Something called ¨malabsorption¨ continues for 3-5 years – this is where the vitamins are not absorbed completely by the body (you need to take supplements).

One interesting side-effect of this surgery is that your glucose levels stabilize *immediately* - if you have Type 2 diabetes or glucose intolerance, 90% of the time the surgery itself cures this. This is because the section of intestine that triggers glucose over-production is bypassed – so no more triggering. This has led to a modified surgery for people who have Type 2 diabetes without a weight problem. They have been doing this in Costa Rica now for 5 years, with a high cure rate (~85%). The USA is a bit behind the times – the procedure is not FDA approved (yet). Cynics believe this is in large part caused by the pharmaceutical industry – diabetes is a real cash cow in the states, so why would they want it cured?

Some of the differences in health care here in Costa Rica are mind-boggling!

• Everything happens at its own pace, so sometimes appointments take hours (much of it waiting). But of course, that has happened plenty of time in the states too. However, most of the time, appointments were spot on.
• I had a consultation with the surgeon ($48), and left with his cell phone number – and instructions to call at any time. Over the course of the surgery and recovery, we must have called him over a dozen times – each time, he was happy to hear from us (really? Well, it seemed like it…).
• Once we got the surgery go-ahead (passed all the pre-operation tests), we paid for the procedure. This included all the visits to all the doctors, all the tests, and over a week´s worth of prescriptions. It also included a follow-up endoscopy at 6 months.

The question of insurance requires its own entry…

June 07, 2007

No big news, just a few tidbits...

There is a group of Harvard students here to get a week of orientation. They will be in Costa Rica for a year, helping to teach English to high-schoolers in small towns. One of them turned his ankle, and so I gave him one of our tubes of Aspercreme and our elastic bandage. The guy who is leading the group was a student at Montaña Linda, and stayed with our Tico family some time ago - so we had met him before.

Rick just got a massage - 45 minutes for about $6. I get one later this week - can´t wait!

We helped Mariala (one of the daughters in our Tico family) set up an email account, so now she can write a friend (and us!).

I taught Mariela´s son how to make the horse-running sound by slapping your legs - now he points to my boots and says ¨más!¨

I told Dad´s joke to Katia´s family - first in Spanish (wow!), then in English Of course, it is much easier to get away with it in Spanish when you tell it ¨live¨ instead of writing it...

A group of cowboys was out on the range, when the cook died. None of the cowboys wanted to cook, so they drew straws. The one who got the short straw said, ¨ok, I´ll cook, but the first person who complains will have to take over.¨ Well, meals came and went; they were pretty bad, but no one wanted to cook, and so no one complained. Finally, the new cook had had enough - he was sick and tired of cooking. So, he cooked up a big batch of beans, and added a _ton_ of salt; he thinks to himself, ¨this will do the trick!¨ Well, the cowboys all get their bowls of beans, and dig in. Suddenly, one cowboy sputters and yells, ¨my god! these beans are salty!¨ A gasp rises from the camp, and he realizes what he has said. Then he quickly says, ¨but that´s the way I like ´em!¨

Katia´s daughter told us a joke in return. A drunk stumbled up to a pulpería (a small general store), and asked the owner, ¨how many bumps are on my head?¨ The owner said ¨5¨ and the drunk said, ¨oh good, only 2 more lightpoles till I get home.¨

Did you know that shackles are called ¨esposas¨ (wives)? Hmmm.
If you get dust on your shoes when someone is sweeping, you will never get married.

June 03, 2007 - Sick in Paradise

That´s Sick IN Paradise, not Sick OF Paradise...

Rick has had a huge head cold for almost a week now. It peaked on Friday, and so Saturday I went to the Farmacia for the good stuff. Up until then, we´d been using the grocery store for Tabcin (pretty good, but not strong enough now), and the market for lots of chicken soup.

Making the chicken soup was actually pretty interesting - I went to the veggie stand on the corner, and started listing items I wanted. At intervals, the owner would say ¨anything else?¨ (ok, really ¨¿algo más?¨). Finally, I asked him if he could recommend anything more for sopa, or olla (soup or stew). He and another customer added a couple of more interesting veggies (I don´t remember the names ) and told me how to cook them (put them in the soup whole, then peel them afterwards). All that help AND the veggies set me back 400 colones (about 75 cents) - and I got called ¨princess¨ while I was at it (that´s a good thing)...

The Farmacia was quite an exhilarating experience. Thankfully I´d had some Spanish. It wasn´t as anxiety-producing as I expected; I made myself understood, the pharmacist asked important questions (and I could answer!), and I left with medicines and instructions.

Rick is a LOT better today - tired of being cooped up, and ready to at least say hello to the world again. And we have plenty of meds to keep him that way :D

Visitors to Hospital Mexico

You can see our friend Joe's account of his experience with hospitals in an earlier post. Here is our experience *visiting* him. Rick and I agreed - we're very glad our first trip to a public hospital was as visitors. Now we will be a bit less worried when we go as patients (you know it will happen eventually).

So, after getting our Cédulas and driver's licenses in San José, - yes, all this on the same day :)

We catch the Alajuela bus towards the Hospital México, and ask the driver to tell us when we get there. He says he will, but... Of course, we miss the stop. We get off on the next stop - fortunately not too far, walk back and on to the Hospital. The hospital is like a circus, so we ask for help at an information window. They can't find Joe for quite a while, but finally tell us he is still in emergency. At about 4:00, the nurse leads us downstairs, and we wave to Joe through the window. She tells us to wait for the Doctor; it should be about 20 minutes. Well, about 4:30, we walk back to where we saw Joe, and the security guard shoos us into a waiting room - we have to wait for visiting hours at 5:00. Linda is there right before visiting hours start - she's been through this before; we give Joe's name, and they let us see him one at a time for about 5 minutes. He seems ok - he has a full face oxygen mask on, and can't talk without taking it off - we're just there to let him know we are looking out for him.
5:15 - we're back on the bus to Alajuela; it's rush hour, so we don't get to the last stop for another hour.
Boy, are we tired! We have our leftovers and conk out.

... The next day...

We caught the 11:00 bus from Alajuela, and got off at the correct stop for Hospital México. As we got off the bus, a very nice lady helped us cross the "muy peligrosa" street. She just grasped my hand, and we followed when she crossed. I am finding that this is so typical - so many helpful citizens. I felt like a Boy Scout in reverse :D

At the hospital, we go directly to the emergency waiting room (doesn't that sound like an oxymoron?), and wait for 12:00 visiting time. Linda appears, and we queue up. Then we find out that Joe is no longer in the emergency room (why didn't we check on this before?). We run around for a few minutes, then Rick asks the right guy - we have Joe's bed number, but (of course) visiting hours for the wards don't start until 2:00. So, Linda drives us all into San Jose, and we go to ARCR to get our hands held. Annabel is very nice - she talks to us a lot, and we feel a bit better about the situation. The hospital will not release Joe just to get him out of the way (what were we thinking?!?).
We grab a bite to eat, then head back to the hospital. My navigation skills are excellent - I was always able to point to the correct turn-off as we passed it :(.
At the hospital, we get in the line for the 6th floor visitors just before 2:00 (we're about the 4th group). Well... The people who run the visiting center don't even show up until 3:00 - by this time, I'm sitting down, and Rick and Linda are very tired of standing. To accommodate the long lines, the hospital folks had opened the doors to the outside. It was very strange seeing all these people zip up jackets and pull up their hoods against the breeze. It had to be 74 degrees! I guess it is all what you're used to.
We got to see Joe one at a time, but there was no time-limit. He was *much* better! He gulped down the yogurt drink I brought (he probably wasn't supposed to have it tho). He had a better oxygen system - no full-face mask, so he could talk easier without reducing his oxygen. He told us about the other patients in the room (there were 6 beds in the room). He said he is very happy with the care he is getting at the public hospital (all covered by his $36/month insurance).
Linda drives us all back to Jalapeño's in Alajuela - whew!

Joe's Hospital Adventure

Joe is our friend in Grecia - he is kindly allowing me to post his recent hospital experience.

(March 2006)

I´m happy to share my days off the radar.

I sure consider it a happy ending to a very scary experience and one that had so much drama and unfortunately sadness too. I think this will be an interesting narrative of my latest Costa Rican adventure and it won’t always be a pretty picture so the sensitive and those with weak stomachs are forewarned.

On a Wednesday I was feeling kind of down and not really breathing right. I assumed it might be a little congestion and when it got worse that day I dropped in on my doctor for advice. After a couple of days of typical cold therapy and no improvement the doctor had some x-rays done and decided if no improvement by Monday I’d go into the hospital for oxygen therapy. By Sunday night I was miserable and at 6 AM on Monday morning I yelled at Linda to call 911 and I collapsed into a chair and pretty well lost consciousness. A Red Cross ambulance arrived with just a driver and fortunately the house construction crew from across the street was just arriving and they came over and carried me on a stretcher downstairs and out to the ambulance.

I was brought to my local hospital and they stabilized me. My blood pressure was barely readable and I was hardly breathing. My doctor met us there and he recommended transfer to a private hospital, CIMA, where I had my hip surgery done. First mistake! I was admitted to CIMA and entered an intensive care room and ended up spending five days there. During that time I had a barrage of tests and it was determined that I had pulmonary hypertension and embolisms in both lungs. I was hooked up to all the standard ICU devices including some very uncomfortable and personal ones that were just down right nasty.

I had a cardio guy, a pulmonary guy, an internist and other specialists all poking and prodding. On the third and fourth days my lung doctor said I needed an infusion of some medication into both lungs to liquefy the clots and after that an insertion of a device into my lungs that would filter any future clots. He literally leaned over me and nose to nose he told me that if I didn’t have it done I would die. I told him I did not have insurance, I did not have the money for such procedures and there must be some other way. Still nose to nose he said to call my friends and family and ask them to pay or I was going to die. I told him to transfer me to a socialized medicine hospital where I had insurance. The next day I went to Hospital Mexico.

I was admitted into an observation room shared with 50 or so other patients under observation and evaluation and those determined most urgent were admitted into a ward. I went almost immediately to the intensive care floor. This hospital is one of two research hospitals in the country and it has 600 beds, specialized buildings attached, e.g. eye specialties, physical therapy and others.

I was hooked up once again to all the typical fluid drips, electro recorders, waste eliminators, oxygen and who knows what else. I shared a room with six other patients, all intensive care and all in awful conditions. I was medicated and put to bed for the night. I know I was visited just about every hour by those recording vital stats and giving shots for who knows what. I woke the next morning to 11 Spanish speaking doctors all reading my chart from CIMA and doing their own touching, listening, and feeling. I´m not so sure I wanted to understand all they were saying anyway so the babble was almost comforting. As a result of this conclave, I went down stairs for echo cardiograms, x-rays, blood work, electro cardio grams and other various look/see tests. That afternoon I was visited again by my ¨team¨ and this time they were looking at their records and pictures and making their own evaluations. At the end of their examination, two of the doctors stayed behind to talk with me, in English!

I had been told numerous times that one of the most difficult things to handle if ever staying in a Costa Rican hospital was that no one speaks English. On the contrary, most of the doctors, many of the nurses and quite a few of the general help speak some level of English and the doctors speak it fluently.

In a very professional manner the doctors that spoke with me, and who I found out were my personal doctors, told me that CIMA´s diagnosis was not completely accurate and I did not have pulmonary hypertension. I did have embolisms in both lungs and I also had a deep vein thrombosis that extended my whole right leg. They said that that clot in my leg was the result of my surgeon at CIMA prescribing a blood thinner for only six weeks instead of the necessary three months and the clots in my lungs had come from the DVT in my leg. They also suggested that the correct way to treat my condition was with an immediate Coumadin drip and a continued oral treatment for an extended period of months. They said this would correct the blockage in my lungs immediately and protect from a recurrence.

This was started while they stood there and I was also given medication to make me comfortable and help me sleep. On the fifth day of hospitalization I was breathing almost normally, blood pressure was better than it had been in years and I was actually aware of my surroundings and other occupants. I was also aware that other than those tasty liquids dripping into my veins, I hadn’t eaten any solid food in, oh… three years! A real breakfast showed up, well a typical Tico breakfast of a hunk of papaya and a big slice of crispy bread with a black bean spread on it and black coffee. I managed about two bites and found that that was about all I was going to eat at any of the meals I ate while there. It also accounts for the twenty pounds I lost while I was there.

I continued to improve and the hospital staff continued to take blood pretty much every two hours, take x-rays and test for whatever they thought necessary. The team evaluated me every morning and my doctors met with me every day to probe my general feelings and to keep me informed of their intentions and my progress. I had lengthy discussions with them regarding the health care system, how it works and how good it really is. He admitted that the small hospitals in the system, like the one in my hometown of Grecia was perfect for emergency situations and the clinic it ran, however they did not have the ability to diagnose nor treat more serious conditions. I would, in fact, be going to Hospital Mexico for all my follow-up appointments and I should consider them my doctors from now on.

After spending a few days detached from my life saving umbilicals and walking the hallways to regain my strength and build up my stamina, I was delivered home by a Red Cross ambulance. I was sent home accompanied by a month’s supply of seven different prescriptions. I’ve been home now four days and feeling great, eating less than normally which is a good thing and behaving normally which is not a good thing. I am counting every day as an added blessing and not taking one breath for granted.

So ends my gentle description of the past weeks events and now I want to share other experiences and a few opinions. Some may not want to read further because I am going to be graphic in a few instances.

My trip to the hospital in Grecia from home was done with little awareness on my part and my stay in CIMA was in a private room so there’s really not much to tell about either. My stay at Hospital Mexico however was dramatically different because I was aware, I shared a room with six other people and my bed overlooked the main corridor and nurse’s station. There was no door in my room and other than the caregivers pulling the curtain around the bed when they gave a patient a bath, there was no privacy.

Other than the cardiac wing, the most intensive supervision and care was given on my floor. There are no law suits in Costa Rica so doctors are not under that threat when they want to treat a patient. For that reason they will do things here that you would never see happen in the states. A man in the bed immediately to my right, four feet away, was in a coma. He was a boxer, in his 30´s, and suffering from multiple brain tumors. His prognosis was the worst. One afternoon, his team of doctors was holding one of their daily discussions, unintelligible to me. It wasn’t until later when I had a chance to talk to my doctor who was a part of the coma patient’s team also that I found out what actually occurred.

As the discussion ended draped carts started to roll in and get positioned around his bed. Some of the doctors returned, gowned and masked, and it was obvious they were about to perform surgery. Surrounded by me, four feet away, and four other patients in their assigned beds, they opened this man’s leg from groin to ankle and inserted some kind of device that led from his leg and terminated in his brain via a blood vessel. The doctors had determined that this patient had one more opportunity to regain consciousness and that was if he did for just a moment come out of the coma this device would ¨fire¨ and continue to stimulate his brain and keep him out of the coma. Remember, my doctor only told me this later on.

After closing the wound, the doctors were picking up and discussing whatever. While this is going on the patient blinks, the device fires and there he is delirious but out of the coma! Talk about emotional. He was attended to and immediately he and his bed were moved to some other ward.

I watched a 19 year old with juvenile diabetes have his foot infection cut away every day for five days in a row, in his bed and moaning in agony. They were trying to save as much of his foot as possible and would only cut away those signs of gangrene.

A very elderly man was being treated for cancer and they were keeping the pain down. His daughter and her children were there as we all watched his heartbeat and breathing work down and stop. We all shared in their loss.

I became friends with a woman and her mother as they cared for a 47 year old man, brother and son, who had fallen in the shower, broke a hip and hit his head and had not yet regained consciousness. While the hospital took care of the life support needs, the women took care of his comfort and their own need to be compassionate.

While I was there I met another gringo who was just about to leave the hospital after three months. He was admitted paralyzed in both legs and diagnosed with a bacterial infection. He was leaving, able to walk, but with a lot of therapy ahead. Another gringo, 47 years old and a resident of Costa Rica for the past 27 years was admitted with a collapsed lung, emphazema and spots on his heart. Not a good prognosis. I have visited him since I left the hospital and he does look better.

I was able to watch the care and how it was given while lying in my bed. I can evaluate the care I received in this socialized medicine hospital and compare it to the care I’ve received in private hospitals both here and in the States. I can say that I would not hesitate to be admitted to Hospital Mexico again, in fact, I don’t ever want to be admitted to a private hospital again. I have never experienced more caring doctors and nurses, not seen so much attention and an effort to do the right thing and a real evaluation of the treatments to be used without the consideration of money.

My five days at CIMA produced a bill of $5400. Sure, intensive care is expensive, however this was but the start if I had ok´d unnecessary surgery and devices. My stay at Hospital Mexico cost me nothing other than the $36 a month I pay for insurance. My follow-up visits to my doctors will cost me nothing. The prescriptions I went home with and every prescription that will be written in the future will cost me nothing.

Right now, I feel confident that I have an excellent health care plan. Hopefully I can avoid getting run over by a bus or swallowed by an over anxious volcano. I am very dismayed by my experience with the major private hospital here in Costa Rica, one that is associated with Baylor University in Texas. Yes, my new hip is excellent. However, the treatment following the surgery almost killed me. The obscene pressure to buy a device and have it inserted in my body wasn’t bad enough, but to know that it was unnecessary and coupled with a misdiagnosis is criminal. Don’t even mention the word litigation. Nope, doesn’t exist and I’m not interested. There’s way more value to me knowing and acting accordingly.

So, there it is, another adventure in paradise.

Love to you all,

a breathing and happy Joe

Wheelchair Magic, and more Angels

May 2006

Two days before the end of our May 2006 trip, and late in the evening (after 8pm), Rick’s back went WAY out. Isabel was a *huge* help. She called a taxi for me, told the driver which pharmacy to take me to, asked him to wait and then bring me back. Then she wrote down medications for me to get. When I got back with them, she took care of injecting them in Rick. Here you can get a syringe, and inject-able anti-inflammatory and muscle relaxants – over the counter! For $8!

Time to leave...

4:30 a.m. - We're up! We are almost packed when the taxi arrives, so we get everything zipped up and downstairs, then Rick stands and walks for the first time in 2 days. He gets in the taxi, but is in some pain. We make it to the airport, get a wheelchair, and get our exit fees paid. Then we find out that a wheelchair cuts through a *ton* of lines!!! We zip right to the ticket counter, and start checking bags and getting checked in. But then Rick's back starts hammering away. The ticket counter person starts saying things like “Can he fly? I don't think he can fly. There's no turning around after we take off...” I abandon the ticket counter, and we take Rick to a place he can lie down. I don't know what to do, but fortunately, *someone* does. The airlines call the Red Cross (Cruz Roja), and the paramedics show up. They have a doctor who speaks English, and a medic who speaks a few words – both are concerned, professional, and kind. They give Rick a shot (I show them the medications that Rick got last night, and there is no problem). Then one of them walks with me back to the ticket counter, and the person there changes our tickets – on the spot, no charge, because she can see that there is a medical reason. We change to a Saturday flight (if we have to change it again, we need a Dr. note tho). I go back to where Rick is recovering, and the paramedics make sure he is ok. Then they help us call the hotel, make sure it is ok for us to return and stay extra, then they get a taxi for us, help me get the bags, and walk us to the taxi! I suddenly think “I don't know how this works! Do they bill us? Do we pay with a credit card?” So I ask, and they say that it is free! That is what Cruz Roja is for!! Well, I lose it again. It is all I can do to stammer out a Muchas Gracias (I think I embarrassed the poor medic).

We get back to the hotel, and Isabel and Norman have already set up a downstairs room for us, and talked to the couple that was going to move from the overflow apartment. They are all just too cool about the whole thing. And this is all before 10:00 a.m.!

I go out for more back drugs to last us till Saturday, then collapse for the rest of the day – food gets delivered.

Two days later...

Up early again – we leave for the airport, and get the magic wheelchair again. Rick is feeling a *lot* better this time, but still needs the chair. I'm not saying it is worth it, but that thing it like a “jump to the head of the line pass” at Disney land! We cut straight to the ticket counter, cut around the security gate line, and were waiting at the terminal within 15 minutes of arriving! Then the gate changed ;(.

By then they had taken the chair away, so I got help at the desk. They sent another chair, we changed gates, then boarded early (skipped another line). When we got to the Miami airport, we waited till everyone else got off, then they brought a wheelchair, Rick got in, they walked us around the immigration lines, we got our bags, then walked around the customs lines, around the security gate lines, and out to our gate. The woman who was our pusher :) was from Costa Rica, so we had some great conversations.

We got back to Oakland, I went and got the rental car, and we're home!