Saturday, November 17, 2012

Central American Madness; Stage II: The Accident

This is Part 2 of a multi-part feature about my recent trip to Costa Rica and Nicaragua.  You can find Part 1 here if you missed it.

Stage II:  The Accident

Wed, 24 Oct (continued):

a road outside La Fortuna, relatively near the scene
About half a kilometer down the road from Baldi Hot Springs I saw several cars pulled over to the edge of the road and traffic temporarily stopped.  A few men were huddled on the left side of the road, and they started waving me over, though I couldn't yet see what was going on.  As I got closer I saw Brit's dirt bike parked in the grass a short distance beyond where the men were standing.  They directed me to park in the same area, and as I rode past them I saw Brit, sitting in the grass on the side of the road, holding his left shoulder and looking shaken.  His helmet lay on the ground a few feet away.

At first I was slightly in shock, a little incredulous.  I quickly parked the quad by his bike before running over to him; as I took in the scene, the man standing in front of him mentioned he thought Brit's collar bone was broken.  I asked if he'd called an ambulance, and he said he had.  Then as now, I was impressed by the quick response of the passers by.

I was exhausted (stayed up late with Fred the night before) and in a bit of a trance, but as I shook it off my little bit of medical training started kicking in: I noted that Brit was conscious, he appeared to be breathing without difficulty, and I couldn't see any bleeding other than a large scrape on his left knee.  My next thought was to to check his mental status, as I assumed he'd hit his head.  I asked him his name and he said, "I...I can't remember."  Then I asked him where he was, and he had no idea.  So I told him where we were and what had happened.  I asked if he could move his left leg and if it was causing him significant pain; he was able to move it fine, though slowly, and said it didn't hurt much compared to his shoulder and his head. 

The ambulance arrived shortly; the paramedics asked what had happened and put him in a neck brace and on a stretcher.  One of the bystanders was nice enough to call the guy we had rented the ATV's from so he could come pick up the vehicles while I rode in the ambulance with Brit.  We were taken to a small local clinic that sort of doubled as an urgent care...and that's when I realized that there were no hospitals in this town (La Fortuna).  A doctor examined him, agreed that the clavicle was broken, ordered some bandaging for his leg, and asked him questions to check his mental status.  Brit still couldn't say where he was or what had happened, and  that trend continued for some time; each time I reentered the room, he would again ask me, "Ben, what happened?", or "Where are we?"  There was a slow, deliberate rhythm to everything he said.  It was more than a little disconcerting to see Brit acting so differently from his usual self.  

The doctor and I were both concerned about internal bleeding (an intracranial hematoma) as a result of the head trauma, and so we needed to get him to a CT scanner.  But the doc said there were none in town.  And the nearest places that could do a scan (such as ciudad Quezada, an hour's drive to the East) were not adequately equipped to treat further if they found a problem.  So he suggested, and I quickly agreed, that we needed to take him to to a better hospital, in San Jose (the capital of Costa Rica), even though that was three hours away.  He said he knew a good one there, and that he'd call ahead to let them know we were coming.

Fortunately, we had already checked out of our hotel.  So I only needed to settle affairs with the owner of the ATV's and retrieve our rental car before leaving town.  The doctor and I decided the best plan was for me to follow the ambulance in the rental car, so that we'd still have it later if we needed it.  I wasn't sure if there was was anywhere to return it nearby anyway.   

So we took off from La Fortuna, the ambulance leading the way and I behind, on a 3-hours drive to San Jose. 

Now might be a good time to explain that:

A) Driving conditions in Costa Rica are crazy compared the US (if you hadn't figured that out yet),
B) This drive included only single-lane highways, a ton of speed bumps, and even a stretch of unpaved road,
C) I'm not very experienced driving stick shift, I've never actually owned one,
D) It was imperative that I stay right behind the ambulance during the whole drive because if I lost him I'd probably never find him again, and 
E) The roads are full of slow trucks and other annoying vehicles, some of whom are very poor at staying in their own lane.  

I should also point out that cars don't really get out of the way for ambulances in Costa Rica.  The driver only used his siren some of the time, and even then it didn't make much difference (other than his not having to pay tolls).  

With all that in mind, imagine me following this ambulance in my stick-shifted Toyota Yaris, having to keep up at all costs as he passed slow truck after slow truck (not to mention poor Brit riding alone in the ambulance, with a killer headache and a broken collar bone on bumpy roads).  I got cut off several times, especially while passing through cities and town, but always found a way to catch up again, even when that involved a lot of honking, yelling, or waving my arms out the window like a maniac.  We never stopped.  At one point during the drive, as I was trying to pass a blue pickup truck whose driver was acting very drunk, I was forced to veer left and both wheels on the left side of the car momentarily slipped off the road very near to a precipitous embankment.  I steered hard to the right and the wheels somehow popped back up again.  Overall, the drive was ridiculously insane, and I don't think I'm exaggerating.  Still not sure how I got through it (other than adrenaline and divine providence).

But we made it to the San Jose area and around 6pm, just in time for rush hour, and shortly thereafter pulled up to the emergency room of a hospital called CIMA (Center for International Medicine Advanced) (no, that is not a typo).  Their website says it's the best hospital in Costa Rica, and I believe them.  

Brit's condition hadn't changed much when we got to the hospital--he was still repeating questions, and he seemed quite lethargic.  But it was in the ER that he started coming around, and was able to carry on a coherent conversation for the first time since the accident, though slowly.  I had to leave him for a while to fill out paperwork, and by the time I finished they had taken him to get a CT scan of his head and an x-ray of his left clavicle.  He had been vomiting during the ambulance ride--in fact, he said that was the first thing he could recall after the accident--and continued to do so in the ER.  They gave him pain meds and an anti-emetic, which seemed to help.  (By the way all the drugs they use down there have different trade names than here, and some aren't used here at all.  So it was confusing trying to figure out what they were giving him.)  At first they said they were gonna put a couple stitches in his knee, but later opted to clean and bandage it with copious amounts of antibiotic ointment instead.  

the view from the hospital parking lot
Overall he was in the ER for about 1.5 hours, half-asleep for most of it, before a room opened up.  The ER doc spoke English impressively well, and was very helpful.  He said they would keep Brit in the hospital for at least 24 hours per head trauma protocols, and possibly longer depending on how tests came out and his symptoms progressed.  I found it interesting that the ER doctor continued to manage his care after admission, as you wouldn't see that in the United States. 

So Brit got a room, and thankfully the CT came back clean (no signs of intra-cranial of bleeding).  But he continued to have symptoms, such as nausea, vomiting, and a headache, that were suggestive of increased pressure in his skull.  Furthermore, the x-ray of his collar bone showed about a centimeter of displacement, and the ER doc thought he would probably need surgery.  (I was incredulous about this from the start, though I didn't say so.  We'd just been taught in orthopedics class that if the two ends of a clavicle are the same room, it'll heal.) 

Brit rested as I took care of odds and ends such as emailing our roommate BJ to get Brit's insurance information (he had left his card at home) and bringing in some of our luggage.  When I ventured out briefly to grab dinner, I discovered the hospital was located in a surprisingly nice area.  I strongly considered calling Brit's parents, but eventually decided to wait till the next and day and ask him about it again after he became more lucid.  Around 11:30pm we got a surprise visit from the neurologist, who examined Brit and asked a lot of questions about the accident and about Brit's memory loss.  Among other things, he explained two scenarios that happen commonly after head trauma, one of which described Brit's history (of repeatedly asking the same questions) nearly perfectly.  

Thurs, 25 Oct: 

Nurses came in periodically through the night and early morning to check on Brit and take his vital signs.  For some reason his blood pressure was really low in the morning, but it picked up as the day went on.  I went to the International Insurance Office first thing to provide his info and see what we could find out about coverage (they said they'd call and to check back in a few hours) before getting breakfast at the hotel cafeteria, which in a bizarre coincidence was called "Cafe Britt".
The orthopedist dropped in mid-morning for his consultation.  He explained that old-school docs probably wouldn't recommend surgery, but some newer ones might.  Brit made it clear he would side with the old-school docs.  And after that he was finally able to eat again!  We hadn't eaten breakfast or lunch the day before since we were busy running around, and Brit hadn't eaten anything since the accident (he was NPO as soon as he got to the hospital).  So by now he was wasting away a little bit.  He appetite was meager at first, but we were both impressed with the quality of the hospital food at CIMA.   

As the day wore on, Brit received additional visits from the ER doc, the neurologist, various nurses, and other hospital staff.  They decided he was well enough for discharge; they also suggested he return home as soon as he was able.  Having already reached this conclusion, we had called Spirit Airlines earlier to change his flight.  And though they again proved antagonistic by charging a ridiculous change fee, by this time we were just glad we could get him home the next day, and from San Jose (rather than Managua as previously scheduled).    

Back at the International Insurance office, I found out Brit's health insurance did provide coverage in Costa Rica, but they said they would reimburse him later rather than paying the hospital directly.  But none of this mattered because his deductible was way too high, so we got to pay for the whole bill out-of-pocket before leaving.  It's not quite like the US where you can show up at an ER without insurance and they'll take care of you without asking a lot of questions.  (I actually think it's perfectly reasonable to expect payment for services rendered, but the contrast with our domestic policies was striking.  Apparently Costa Ricans are not as entitled as Americans.)

We left the hospital in the late afternoon, just hoping to find reasonably priced accommodations somewhat near the airport, so Brit could rest and easily catch his flight the next day. 

What seemed like an easy enough route on the map from San Jose to the nearby city of Alajuela turned into a bit of a nightmare, at least for me.  Brit seemed to be half-asleep during most of it, so I'm not sure what he remembers.  Some of the features of the drive that I did not like include:  Wrong turns; a dearth of road signs; a dirt road with a ridiculous number of pot holes; Brit wincing in pain as I drove over said pot holes, despite only going about 3 kilometers per hour; stop-and-go traffic during rush hour, in the dark, in the rain, up and down steep hills, using a stick shift; stopping for directions at least three times but never finding what we'd been directed to; confusing roads in completely unfamiliar territory; Brit wincing in pain some more. 

Hotel Bordel
Finally around 8pm we pulled into Hotel Bordel, not far from the airport.  It was by far the most expensive place we'd stayed during the trip, but also the nicest.  And it was definitely worth it, due to the convenient location and a free shuttle service to the airport, not to mention free breakfast, cheap laundry service, and air conditioning.  Brit went to sleep right away; I stayed up pondering where I'd go after he left.   

 Fri, 26 Oct: 

I tried to help where I could as Brit struggled to dress and pack with a crappy headache and only one usable arm. Eventually he was ready to go, and he even ate the full complimentary breakfast of gallo pinto, eggs, and toast--by far the most he'd eaten in one sitting since the accident.  Around 10am his driver arrived, and we said our goodbyes.  I was sad to see him go, but also glad he'd soon be with friends and family who could take better care of him in a more comfortable environment.  It was definitely the best thing for him at the time.

As for me, I was now alone, with three days to find my way up to Managua, Nicaragua (and maybe even have some fun along the way).   

The story concludes in Part 3.  

Monday, November 12, 2012

Central American Madness; Stage I: The Trio

I just went on a 10-day trip to Costa Rica and Nicaragua.

It was incredibly fun, I loved being there, and awesome activities abounded.

It was also just plain crazy, did not go as planned, and was an adventure I will never forget.


My friend (and roommate for the past year) Brit Hatch had the idea and did just about all the advance planning for the trip; our friend and schoolmate Fred Fombrun joined us for the first half-or-so of the trip.  It was our last break from school before starting clinical rotations, so we wanted to do something fun and memorable.  Though we were in school and taking finals till the day we left, Brit somehow found time to meticulously research our itinerary and make several reservations.  (Thanks again Brit for all the time and effort you put in to prepare for this!)

Below I will describe the events of the trip, day by day, for your reading pleasure. 

But first, a quick note about third-world countries:  If you've never been to one, it may be difficult to properly contextualize the following events.  For that reason, I demand that you immediately plan and execute a similar trip before you continue reading. :)  Just kidding.  But try to use your imagination--it was not at all like being in the US.
Stage I:  The Trio 

We began as three. 

Fri, 19 Oct:  Departure day.  (Not to mention our last day ever of class for PA school!!)

Once school got out around noon, we had the rest of the day to shop, pack, and generally check off all those tasks you gotta do before leaving the country for 10 days.  Our red-eye flights were scheduled to leave around 10pm.  

And things were going smoothly until a couple hours before our flights, when Brit informed me that there were no open seats on his and Fred's stand-by flight. 

You see, Brit and Fred had used "buddy passes" to buy stand-by tickets  on US Airways, while I had purchased a flight on Spirit Airlines (perhaps because I have more than a little history with stand-by flights).  And now both of them were in jeopardy of not making it to Costa Rica, or being significantly delayed in doing do.  Their other option was to purchase a last-minute ticket on Spirit, but the price for those had shot up to $500 (one-way), since it was so last-minute.

So with Brit and Fred mulling it over and making calls to all their favorite customer service representatives, we headed to the airport.  Upon arrival, they both tried to buy outrageously-priced tickets for the Spirit flight, but now there was only one of those left.  Fred bought it, and Brit was forced to take his chances standing by on the (full) US Airways flight as originally planned.  When we parted ways in the airport, Fred and I didn't know if or when Brit would make it to Costa Rica.  And we didn't find out until our layover in Ft Lauderdale five hours later, when Brit called us from Charlotte to let us know he had made it on the flight, barely, with the last seat.  Thank goodness. 

(A quick note on Spirit Airlines:  They have decided to antagonize all passengers by making seats that don't recline.  I do not approve of this, especially for red-eye flights, and I will do my best to avoid them in the future.) 

Sat, 20 Oct:

Fred and I arrived in San Jose, Costa Rica around 11:30am; Brit's flight wasn't far behind, and we met up just beyond Customs. 

After skipping past some money-exchanging stations (a good choice in retrospect--turned out their rates were the worst we'd see) and tourist info, we made it to the car rental area, where representatives from several different agencies were crammed into one small room with  little desks.  Kind of a funny setup, but it made it easy to compare options.  After due diligence, we opted for a four-door Toyota Yaris from National, mainly because they said we could drop it off right at the Nicaraguan border, rather than a city that was 80 kilometers away from the border.  (Yes, everything is in metric in Costa Rica.  Get used to it.  We did.)  We'd been told it would be smart to get an SUV for the rough terrain in some parts, but we decided to take our chances with a car since it was cheaper, got better gas milage....and hopefully wouldn't get stuck even if it took a beating along the way.  And that's exactly how it went.  (And in case you were wondering, it was a stick shift, because automatic transmissions practically don't exist in Latin America.)

The guy at the rental office gave us our very first set of bad directions--the first of many to come.  You see, directions in Latin America are just...different.  They don't really have addresses, and more often than not there are no road signs.  On top of that, the landmarks they choose to mention are not always the easiest to find.  It's pretty mind-boggling...but it's all part of the adventure, I suppose. 

While trying to apply our shoddy directions and get to the main highway, we just happened to drive right by the San Jose (Mormon) Temple.  So we stopped and took a picture.  Somebody should tell the guy at the rental office that the Temple would make a pretty good landmark. :)  It was pretty random that we found it, as it didn't even seem to be on a major street. 

Back on the road, we were treated to an extremely-green countryside and some afternoon showers (a daily occurrence as it turned out, since it was rainy season) on our way to a town near Manuel Antonio national park, which is right by the Pacific Ocean in the Southwest part of Costa Rica.  Along the way we stopped at a roadside diner for our first Costa Rican meal--some "casados"--and made our first transactions with the local currency, called "Colones" (which means "Columbuses").  Colones were pretty easy to figure out because one dollar is worth about 500.  But things in Costa Rica were a bit pricier than I expected (based on experience in Guatemala, Mexico, and El Salvador), presumably because Costa Rica is the wealthiest and most developed country in Central America. 

After a quick stop at Jacó Beach--where some friendly natives decided to climb the trees and fetch us coconuts--the remaining portion of our drive to the Manuel Antonio area was done in the rain and dark; but that didn't stop a ton of bikers and pedestrians from strolling along the edges of this single-lane "highway", with little a care for the cars whizzing by.  When we arrived in the town of Quepos (near the park),  we just needed to find the hostel called "Villas Jacquelina", which Brit had read about online.  But we didn't have an address, and  nobody we asked seemed to know where it was.  Those who had heard of it struggled to give clear directions.  But that was understandable in this instance, as the hostel turned out to be about a kilometer outside the town on an incredibly rough dirt road.  A strange location to be sure, but we were extremely happy to have found it.  We got our own room for only $15/person/night, and we were big fans of the establishment, despite the crappy access road.    

Sun, 21 Oct:

The complimentary breakfast at VillasJacquelina consisted of gallo pinto (rice and black beans cooked together) and eggs, with some toast and fruit on the side.  I quickly grew to love that combo of gallo pinto and eggs, and tried to eat it whenever possible the rest of the trip, usually requesting fried plantains on the side.  In fact, I would like to continue eating that for breakfast every day, if I could just get someone to make it for me.  Any takers??  I will pay you.  

After breakfast, we drove the short distance to Manuel Antonio national park, known for its plentiful and exotic wildlife.  We took a walk through the forest, where with the help of the guide we hired we were able to see several sloths (both two-toed and three-toed varieties), monkeys, bats, iguanas, crazy-looking spiders, and some other stuff I'm forgetting.  One of the sloths put on it's own trapeze show on snapping and crackling branches directly above the walkway, as a veritable hoard of geriatric tourists ooed and awed below.  Luckily it didn't fall, though apparently they often do.  But hey, if you're a sloth, how else do you get thrills?  Once through the forest, we swam briefly at a beautiful, secluded beach.  Then Brit found us an alternate route out of the park by climbing over a large rocky embankment.  I was only scared for my life for a few seconds while following him.  

For lunch we enjoyed fish tacos at a restaurant near the main beach of Manuel Antonio.  After a short chat, the guitar player hired for entertainment invited me to play something for the patrons.  I shared a few songs while he added fancy accompaniments on his guitar; some Americans watching football at the bar cheered loudly for a John Denver special, and one of them even gave me a tip afterward. 

We spent the remaining daylight (it got dark each day around 5:30) at the main beach of Manuel Antonio, attempting to boogie on a board.  The scene was remarkable:  as storm clouds swirled above, gentle showers fell and waves rolled in from the ocean, all framed by rocky embankments and a lush, green forest.  Brit said it reminded him of certain parts of Hawaii.  

On the way home we hit up "El Avion", a restaurant that is literally built of and around an old airplane (allegedly from the Iran-Contra affair), with a bar inside the plane itself, for dinner.  The food was good; the view was great. 

That night Brit taught us how to play Pinoy, a card game he plays with his family which is a cross between Scum and Poker.  It became our nightly tradition.  

Mon, 22 Oct:

With more gallo pinto, eggs, and fruit in our bellies, we left Villas Jacquelina and Manuel Antonio behind.  

What was supposed to be roughly a 4.5 hour drive (estimates varied wildly) turned into about seven hours as poor directions, funky roads, fog, rain, and typically a complete lack of road signs repeatedly led to wrong turns and delays.  We each took a turn at driving.  Passing slow trucks on a windy single-lane highway in the rain led to some tense moments, but we survived.  Finally, around dusk, we arrived in La Fortuna (a quaint, touristy town near volcano Arenal), and had a surprisingly easy time finding Hotel Dorothy, where we were lodged for just $32 (total) per night. 

As it was too late for any of the myriad daytime activities in the Fortuna area, we decided to hit up Baldi Hot Springs.  At Baldi, in addition to a hotel and restaurant, they've built a series of swimming pools, hot tubs, and water slides that take advantage of naturally hot water from springs.  It's allegedly the largest hot springs in the world.  True or not, it was an awesome place to hang out.  Fred and I also sampled the buffet, and then we all went on the water slides (one of which was the fastest I'd ever been on, not to mention in total darkness), before lounging on underwater bar stools in the middle of it of a large pool, watching Monday Night Football.   

Tue, 23 Oct:

For breakfast in La Fortuna, we went to "Soda el Rio"--in Costa Rica, "soda" is another term for restaurant, much like bistro in English.  That was pretty confusing at first-we just thought a bunch of places were advertising soda for sale.  I got the usual (pico, eggs, plantains), and so did Fred...but he also got a steak on the side for good measure.  Fred doesn't mess around when it comes to Costa Rican breakfasts.  

And then it was time to go white water rafting!  The company we booked it with shuttled us about 1.5 hours away to the Sarapiquí river, where we spent a couple hours moseying down the river on some grade 3 rapids.  Though we would've preferred a higher grade, it was still awesome.  The other people in our group were there complements of the Ellen DeGeneres Show.  And since some of them were a bit frail, that might explain why the rafting company picked innocuous grade 3 rapids that day.  We stopped a few times along the river for rope swinging, swimming, and cliff jumping.  At the end they served us some potentially-fresh tilapia for lunch.    

When we got back to La Fortuna, Fred and I challenged some natives to a soccer game at a local park.  We played 3 on 3 (Brit watched, Fred and I played on a team with one of the locals) on a small cement court...and boy did we take it to 'em.  Except not really. :)  But we kept it reasonably competetive, and Fred got to cross that off his bucket list (he's a long-time player of soccer).  After the game I asked if they were gonna play any more, and one of the kids basically replied that their lungs couldn't take any more because they smoke too much marijuana. 

As it was Fred's last night, we stopped by a souvenir shop near the town center.  While we were looking around, all the stuff on the shelves started to shake.  I just thought somebody had just turned on a fan or something, but it turned out to be an earthquake (magnitude of 6.5)!   The epicenter was about 100 kilometers to our West.  I'd only experienced one other temblor, but this one was quite a bit bigger.  

Later we strolled around the town to see if there were any dance clubs where Fred could get his groove on.  Unfortunately they only do that on the weekends.  But we all decided Fortuna was a great place to hang out, and I'll definitely go back.  We rounded out the night with another game of Pinoy.  Fred is the reigning champion because he won the last round by playing progressively higher pairs over and over again.  

Wed, 24 Oct:

Fred needed to catch a bus around 4:30am to make sure he could get to the airport (about 3 hours away) on time.  He would also need to catch a connecting bus in the next city.  Since Fred speaks little Spanish, we taught him a few key phrases that he could use, and told him to keep repeating them if he got in trouble.  I would have enjoyed seeing that in action. :)

We all slept through the alarms and snoozed a couple times, until finally Brit noticed it was 4:20am and told Fred he better go.  Fred was up, ready, packed, and out the door about ten minutes later.  

Fred was gone.  He later informed me that he made it to the airport with plenty of time to spare, but was sleeping on the bus and woke up in the nick of time before the bus continued on to San Jose.  Good thing, otherwise he'd probably still be in Costa Rica. 

About 9am, Brit and I took a shuttle to a zip line course near volcano Arenal, called "Ecoglide".  The course boasted 13 zip lines, each some hundreds of meters in length, high above a thick forest next to the volcano.  They also had a special swing they called "The Tarzan", where you got to jump off a metal platform way up high and swing back and know, like Tarzan.  About half of our group chickened out after they saw the first girl jump off, but not us.  It was a rush.  Overall, the zip line course was great, and the views were fantastic.  Highly recommended.

After Brit and I checked out of Hotel Dorothy, we hoped to rent some ATV's and go swimming at the Fortuna waterfall before beginning the five-or-so-hour drive to our next destination (Tamarindo Beach).  We were pleasantly surprised to find out a guy near the square rented out dirt bikes for just $20/hour, and we could take them wherever we wanted.  Brit got one of those, while I opted for a four-wheeler since I had no experience with dirt bikes.  A short distance up the highway we found a dirt road that we followed for about half the hour before tracking back, crossing a river and discovering some cool scenery along the way.   

It was nearly time to return our rentals when we made it back to the main road; on Brit's suggestion we decided to spend our last five minutes zipping up the highway to Baldi Hot Springs (about a kilometer outside town) before returning the rentals.   

"Let's just go up to Baldi..." 

I led the way on my quad, but didn't look behind me for about 30 seconds.  When I didn't see Brit, I assumed he was just going slow and would shortly catch up.  I looked back a few more times as I worked my way up to Baldi, but never saw him.  I never really worried because I knew Brit was a fairly experienced rider of motorcyles and dirt bikes, but it seemed a little odd.

I got to Baldi, flipped around, and after a few seconds headed back to find out what Brit was up to.  As I rode I felt a mild sense of foreboding; enough time had passed that it was a bit strange for me not to have seen him by now.  

The story continues in part 2.