Navigating the Public Medical Care System (CAJA) at the San Rafael Hospital

I apologize for the length of this post, but I wanted to give as much detail as possible to help others who find themselves in the same position.

I recently wrote a post about how we joined MediSmart and the specialist I went to see. This was regarding a reddish patch of skin on my lower back which I had been living with for several years - first in Canada, then ongoing in Costa Rica.

In Canada, a doctor I had at the time (before 2011) took a look and basically said that it was just a sign of aging. After about four years in Costa Rica with the patch still there, I decided to have our CAJA doctor (a general practitioner) take a look (then 2015). She thought it might be some kind of fungus and directed skin scrapings to be taken and analyzed. When nothing of particular concern was indicated by the analysis, she prescribed a popular skin cream called "Crema de Rosas" and Betametasona (a steroid medication).  I used both for over two years, but the patch lingered on. However, when a new CAJA doctor arrived on the scene (also a general practitioner), I pointed out to him that the treatment did not seem to be doing anything and expressed maybe I should see a dermatologist. He agreed.

Then, the only question was whether to get an appointment with a dermatologist in CAJA or a dermatologist in the private system. I elected for the private system (in this case MediSmart) because first time appointments with a specialist in CAJA can sometimes be long delayed.

Five days after I saw the MediSmart doctor (October 30), he emailed his diagnosis and lab report to me. It was a non-malignant skin cancer confined to the top layer of the skin. He said that it could be removed with minor day surgery - that he could do it under MediSmart or that I could also have it done through CAJA. I decided to check how long it would take CAJA to move forward given the head start report provided by the MediSmart doctor. Not long.

On November 1st, I had an appointment with my regular CAJA doctor, showed him the Medismart diagnosis, and who then issued me a referral for a dermatologist at the hospital assigned to us when we first joined CAJA - the Hospital San Rafael  in Alajuela.

Here is where the fun begins:

In the CAJA system, a "referral" is not an "appointment". It merely opens the door to get an appointment. On November 3rd, I took the referral to the hospital, the purpose being to have a dermatologist assigned to my case and an appointment with that doctor. At the main door of the hospital, a guard looked at the referral and directed us (Lance and I) to reception on the 4th floor. There, there were three reception windows with three clerks and long line ups at each.

It was by no means clear which window was appropriate. But, a prominent sign in front of the third window (as you walk in) listing "Dermatología" and a number of other specialities suggested that window was the right one. A similar sign listing still more specialities was in front of the first window. No signage was in front of the second window.

Logic dictated that we should be in the third window line up.  But, after dwelling in that line up for a period of time, a really nice lady thinking - and rightly so - that we might not understand the system looked at my referral, determined that I was in the wrong line up, and directed us to the second window line up. So we moved from the middle of the third window line up to the end of the second window line up. Once at the second window, I presented my referral and was quickly assigned to a dermatologist and given an appointment with that doctor for four days later (November 7th).

We subsequently learned that the line up at the first window was a line up for able bodied people to get an appointment; the line up at the second window was a line up for preferred service to get an appointment (pregnant, disabled, mothers with babies, and seniors like myself); and the line up at the third window was a line up for people showing up on the day of their appointment. 

With the appointment in hand, was I all set? Not on your life - there was another line up to come. This was a new case, so the case had to be opened and a file had to be created. With a first appointment in hand, this requires the patient to retreat to the main floor of the hospital and get in the appropriate line up at the "Plataforma de Servicios" (Services Platform). There, a clerk reviews the appointment, checks out information on a computer (e.g. are you up to date with CAJA payments) and enters new information. If everything is in order, he or she opens a file and puts a number of print outs in a file folder. Unfortunately, we did not know any of this on the day I got my first appointment for November 7th. We simply went home with the appointment.

For my first appointment, we were told to be at the 4th floor reception area at 1030 for an 1100 appointment. The hospital is about a 50 to 60 minute bus ride from Atenas so we opted to catch the 0800 bus from Atenas. At the Alajuela bus depot it was a short taxi ride to the hospital. We arrived at reception an hour early. My appointment paperwork was processed quite quickly, BUT I did not have a file! We were sent down to the Plataforma to get a file.

At the Plataforma, I grabbed a number from a ticket machine and we sat and waited. The numbers were not moving very fast. I got the bright idea to get a special number for the preferred service line up. Mistake! It must have been new baby registration day because there were several babies and it took ages to create files for them. I should have stayed in the regular line. The numbers you get for the preferred line are not the same as those from the ticket machine which are flashed out on a wall screen. They are obtained by walking up to one of the clerks and asking for a preferred number card. Apparently, it seems OK to interrupt and do that when the clerk is trying to deal with somebody else. With the card in hand, you then have to listen very carefully for the number to be called (and obviously have to recognize the number when spoken in Spanish). 

By the time my number was called, my 1100 am appointment was long gone. But, my file was eventually created and we headed back up to the 4th floor. The reception clerk saw me, waved me in ahead of others, put the file in order and directed me to a waiting area elsewhere on the 4th floor. It didn’t take long to see the doctor (in Spanish "doctora" as it turned out).

Events may have unfolded differently had I tried to get the file opened on the same day that I got the first appointment. I don't know which, but I expect that the file either would have been handed to me with instructions to deliver it up to 4th floor reception before leaving the hospital or would have been kept and routinely delivered by some internal office procedure.

The doctora set an appointment for the next day for what I thought was going to be a minor procedure to confirm the MediSmart diagnosis. I started to have my doubts about this when I was told to put on a gown, booties and a head covering and directed to an operating room where my doctora and two nurses waited. About an hour and a half later, the reddish patch was gone and I was on my way with stitches and a dressing on my back. I had several prescriptions to fill at the hospital farmacia but was told it would take two hours so we left them there and opted to take a taxi home instead of a bus.

Which meant we had to return the next day to pick them up! In hindsight, I should have tried to have them filled at our Atenas clinic farmacia. Live and learn.

My next appointment was scheduled for five days later. This turned into a bit of a fuster-cluck because my file was placed in the wrong consulting office. After patiently waiting (no pun intended) about five hours, we finally told a reception lady that there was no doctor. She was on the phone immediately, we were given a different room number to go to and I saw the doctora right away.

I have two more appointments the last week of November.

Hospital San Rafael is large and modern. The medical staff are excellent, but the administrative system might be deserving of some scrutiny. Go there with a lot of patience as there are lineups for everything. If you have never been there before, it might be a good idea to bring somebody with you who not only knows Spanish but also knows the CAJA system. Parking is very limited. So, if you are going to drive to Alajuela instead of taking a bus, I suggest parking at the Juan Santamaria International Airport or at the City Mall Shopping Center, and taxing to the hospital - it’s not very far from either place. 

At every visit, Costa Ricans helped us out when we were stuck - wonderful people.

I expect that the system is not much different at other CAJA hospitals.

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the San Rafael Hospital 

The End of the Green (or Rainy) Season, Costa Rica

Mid-November and we will soon be moving into the dry season for the next six months. But all bets are off for October and November as far as rain goes. I really needed to do a laundry wash today but this morning was overcast so I put it off until we got back from a shopping trip to Atenas.

By then, a bit of sun was peeking out and there was some breeze. So I took a chance and washed bed linen and some other small items. I told Lance, “If you hear, smell or suspect rain - let me know.” Just before 3:00 pm, the rains came down without much warning and they were quite heavy for a short time. We ran outside and brought the laundry inside in record time. I have the small items hanging from our shower curtain rod and this is how I am trying to dry out the sheets:

That big floor fan is really useful for drying out wet floors and bed linen. Why don’t we have a dryer, you say? It didn’t come with our rental house. Most Costa Ricans don’t have one either - they are expensive to use because of electricity costs here. If we did have a dryer, I would only use it a few times a year - such as today. Moving to a foreign country teaches you a lot of new things!

Fun At the Local Medical Clinic in Atenas, Costa Rica

This morning we went to the Farmacia Clinica in Atenas to drop off a prescription. This is where we go for blood work and medications. Some people have their assigned doctor here, but ours is at the Ebais in Barrio Jesus and it is not that far from our house. We see our doctor and then take prescriptions/requisitions to the Atenas clinica.

After dropping off the prescription, we went to Kay’s Postres Cafe & Restaurante for breakfast. Kay’s is right next to the clinic. I had the BELT (bacon, egg, lettuce, tomato sandwich) and a fruit smoothie, and Lance ordered an omelet. After breakfast, we wandered back to the clinic but my prescription was not ready.

So we took seats and just people watched. There is a clock on the wall that forever says “it’s 10 o’clock”. There is a sign warning against any amorous activities, like kissing. The clinic can be very confusing at first. Some people are waiting to see a nurse or a doctor, others are lined up to renew their carnets (medical cards), people like us waiting for their prescriptions ..... then there are those waiting for the Needle Man.

I met him once - I needed a shot in the butt for some reason or other. He is dressed all in white - shoes, trousers and shirt. He waits for a needle prescription in his inbox and then calls out the name of the lucky recipient. One little girl went skipping happily into his office and came out a few minutes later in her mother’s arms, crying and rubbing her tush.

But the funniest kid (although I guess he didn’t think it was so funny) was the one who must have been told ahead of time what he was going to be facing. He and his father were sitting across from us. The boy (maybe five years old) was complaining, crying a bit, trying to escape. Then his name was called.

He immediately grabbed hold with both hands to his chair arm and his father had to peel him off. Dad carried him towards his fate, but he grabbed hold of door frames and put his feet on walls to stop forward motion. It was like trying to put a cat into a carrier. I didn’t know small children could do this. You should have heard the caterwauling (ha ha) during the needle procedure. Out he came in his father’s arms - rubbing his rear end.

So is it better to warn your kid ahead of time or tell them they are going for ice cream in the nurse’s office?

Coping and Getting Along in a Foreign Country

Arriving home to our house today, after a morning of getting to and from Alajuela by bus for various appointments, then dealing with the appointments. Not as bad as that sounds. Anyway, opened up our gate with too much vigor and the 300 ton gate (yes, exaggerating) sailed away from me, moved off the rails and crashed into the bushes. No way we could move it. 

But wait! I hear our neighbour Sharon talking to the gardeners that remove her garden trash for her. I yelled, “Sharon, can you send over some of those burly guys to help us with our gate?”

She sent over a burly guy and, between BG and Lance, our gate is in position once again!