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.  

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