Jun 22 2011

My Experience Using the Costa Rica Medical System (the “Caja”)

When we decided to write about how the Costa Rica National Health Care System (Caja Costarricense de Seguro Social – “Caja” for short) works, I didn’t realize that I would have an opportunity to write about my own personal experience.  It’s  really scary to be facing a medical problem while living in another country, one in which you are not even close to being fluent in the language, let alone the procedures to be followed to use their services.  What follows is my experience of the Caja last year in our town of San Ramon.  I’m writing this in great detail because so many Expats we know have no experience with this side of the Caja, and so many Americans have fears about health care in “third world countries.”

How It all Started

Days 1 & 2:  I woke up with a tender lump in my groin.  By the second day, it was so painful that I went to see our doctor.  He is a Caja doctor but also sees patients privately, and as a bonus, he speaks fluent English.  He made a preliminary diagnosis of an inguinal hernia and wrote me a referral to see a Caja surgeon for a consultation.

Day 3:  The next morning we went to the Specialists Clinic to make an appointment.  We brought with us my cedula (residency card), carnet (Caja enrollment card), and the referral from our doctor.  The one thing we didn’t have is our receipt showing that we had paid our monthly Caja premium for the current month.  Usually Paul carries it with him, but we couldn’t find it for some reason.  So I waited while Paul drove across town (all of about 8 blocks) to the Seguro Social office where he showed them his carnet and they gave him a duplicate receipt.  He drove to the hospital’s Validacion window where he had his receipt verified and stamped, then walked across the street to where I was waiting at the clinic.  This process took all of 10-15 minutes.  We went back to the window to make the appointment with all of the necessary documents and were given an appointment with a surgeon for three weeks later; not bad, since we expected it to take at least twice that long.

Surgical Consultation

Day 23: Our appointment is at 8:00 a.m. so we arrive at the clinic at that time and give our appointment slip to the Rita, the receptionist.  She doesn’t speak any English but is very patient with our limited knowledge of “medical Spanish” and eventually she makes up a new patient folder and adds it to the pile on the Surgeon’s desk.  The Surgeon has been called into an unexpected surgery and is running late, so we wait with all of the other patients.  After about two hours, Rita informs us that the Surgeon is still operating and we would have to come back the next day.  She gives us our choice of morning or afternoon and we opt for 8:00 the following morning.

Sidenote:  When you are given an appointment for any service in the Caja – blood tests, xrays, doctors, etc. – everyone receives an appointment for the same time and then you receive a number and wait for your turn.  More about this later.

Thursday, Day 24:  Again we arrive on time and find that several people have arrived ahead of us.  We check in with Rita who warmly welcomes us and tells us that my name would be called when it is my turn to see the Surgeon.  A few minutes later, the Surgeon (a different one, we think, from the one scheduled the day before) arrives and starts seeing patients.  She is a lovely woman who speaks perfect English.  We chat for a few minutes and learn that she went to medical school in Vancouver, British Columbia.  She takes my medical history by hand, examines me, and tells me that to be sure, she wants me to have an ultrasound and come back to see her in one week.  She explains that we can check to see if we can have it done through the Caja but it may not be possible to have it done within a week, and she doesn’t want me to wait.  She also tells us about two private labs she recommends where we can have the ultrasound done sooner.  So we leave her office and Rita gives us an appointment for 9:00 a.m. one week later.

The Tests

We walk across the street to the hospital, to try making the ultrasound appointment through the Caja, and are told that the next appointment couldn’t be schedule for at least three weeks.  So we continue on to one of the private labs, located about ½ block away from the hospital, and make an appointment for the next morning.  We are told that we will have the results back the same day.

Friday, Day 25: We arrive at the private lab at 8:00 a.m. and pay for the ultrasound, a total of 30,000 colones (about $55 dollars).  We wait about 30 minutes for the doctor to arrive from San Jose and when my name is called, I am directed to a room down the hall.  The doctor, who speaks only Spanish, does the Ultrasound while, in the back of the room behind a privacy screen, his assistant types the doctor’s findings on a laptop as he dictates them.  The only thing I am able to understand for sure is that it’s NOT a hernia.  After the test, I return to the waiting room and about 10 minutes later I am given an envelope with the typed results of my ultrasound, accompanied by several photographic prints of the test itself.

Even though my follow-up appointment with the Surgeon is less than a week away, I am nervous so I spend the evening translating the ultrasound results from Spanish into English and then doing Google searches to research what he has found.  Of course, many of the possible causes are scary so I am no less nervous than I was before the translation.  The only thing to do is to wait six more days.

Thursday, Day 31:  We arrive at 9:00 a.m. for my appointment with the surgeon and, while we wait my turn, we run into a couple we know who are waiting to see another doctor for their son.  We tell them why we are there and the wife tells us that she recently had surgery for the same kind of hernia for which I was originally diagnosed.  She waited six months for her surgery but, she explained, she had had the hernia for five years before seeking medical care.  In other words, it wasn’t an emergency.


Before we knew it, my name was called and we entered the Surgeon’s office, the ultrasound results in-hand. She reviewed the findings and I was relieved that she wasn’t alarmed at two of the three things the radiologist found…evidently they are normal for a person of my age.  The one finding that she was concerned about, the lump I had felt about a month ago for the first time, was an infected lymph node. I already knew about it from my translation and Internet search, so my expectation was that she would want to do a biopsy.  Neither Paul nor I were prepared for her to schedule me for surgery 10 days later! She would remove the lymph node since it was 2 ½ times the normal size and then biopsy it.

I am strangely relieved that, because the cause of the infected lymph node could be something serious (like lymphoma), I wouldn’t have to wait months for surgery.  It was comforting to know that, while you might have to wait months for routine surgery, when it comes to something potentially serious, you are moved to the top of the list.

She explained that we had the option of processing the biopsy through the Caja or through a private lab.  The Caja, she said, would send the specimen to Hospital Mexico in San Jose and it would take three months to get the results, whereas with the private lab, we would get the results within two weeks.  She wrote orders for pre-op blood work and also blood tests to determine the cause of the infected lymph node. She also wrote an order for my surgery on June 21st and told me to bring it to Ambulatory Surgery across the street at the hospital when we left her office.

Scheduling Surgery

We asked a guard at the hospital for directions to Ambulatory Surgery and quickly found it.  We walked into a small room, painted in institutional green, full of patients and their families waiting for their surgeries.  The room had three doors with no signs on them, no receptionist, and no adornment.  It wasn’t anything like a waiting room in the U.S. but it was clean.  The people waiting told us to go through one of the doors for assistance; (the other two doors turned out to be rest rooms). After walking down a short hallway, we found ourselves looking in the surgical prep/recovery room.  One of the nurses came over and told us that we needed to attend a seminar the following week to go over what to expect and how to prep for my surgery.

Blood Tests

Next we walk over to the part of the hospital where they do blood work and xrays to see if we can have my blood drawn.  We were told, however, that blood draw was over for the day and to return the next morning after 6:00 a.m. but before 8:00 a.m.

Friday, June 11, Day 32:  We arrive back at the hospital for my blood work at 6:40 a.m. and get in line to check in.  I am given number 88, which means that between 6:00 a.m. and then, 87 people have checked in before me. We sit and patiently wait for our turn, chatting with the Ticos sitting around us.  Everyone is in good spirits, even the children.  There are two technicians drawing blood and the line moves quickly.  By 7:30 a.m., less than one hour after arrival, we are finished and headed back to our car.

Pre-Op Instructions

Tuesday, June 15, Day 36:  We arrive at 9:00 a.m. at the location for the seminar, a meeting room at the Health Department, close to the hospital.  There are about 60 people there, patients and their families, all ages from babies in strollers to the elderly.  The one hour seminar started with a woman – a doctor, nurse, or administrator…we weren’t sure – going over the pre-op instructions.  She explained everything from not wearing nail polish the day of the surgery to how to put on the surgical gown.  Though it was all in Spanish, we understood much of it, but to be sure, we met with the woman on the way out to ask our questions.  She said not to worry and told us to return to the room and bring my surgical order to one of the women at the table.  When it was my turn, I gave her my surgical order and she attached it to some forms, gave me a written list of pre-op instructions (in Spanish), and asked me to wait to have an examination before we left.  Over the next 15 minutes, seven doctors/residents arrived, each pulling up two chairs and a stack of patient forms.  Starting with the children first, patient names were called and each in turn sat down across from one of the medical personnel.  There was no physical exam but a thorough medical history was taken on each of us. It was certainly different than anything I had ever experienced in the States, but it seemed to be efficient…we were in and out in a total of two hours.

That evening, thanks to Google Translate, I translated the pre-op instructions into English as best I could.  The instructions explained where and when to arrive the day of surgery, up until what hour the night before I could eat or drink, to bring someone with me, to bring a large bag for my clothing, and to leave any items of value at home – all the same things I would be told to do if having outpatient surgery in the States.  There were a few items, however, that you would never see on a U.S. pre-op list:

  • Come well bathed.
  • Shave the area to be operated, but not if it’s your eyelashes.
  • Come with great patience and willingness to spend all day waiting to be operated.

Day of Ambulatory Surgery

Monday, June 21st Day 42:  Paul and I arrived at 6:00 a.m. the day of my surgery.  While Paul parked the car, I went to the Emergency Room Administration Office, as instructed, to check in.  Then we went on to the Ambulatory Surgery waiting room and took a seat.  There were already several people there, waiting to be called but before we knew it, the room was full.  A small television was on and we all watched the World Cup of Soccer to pass the time.  The hours passed slowly; at noon, I was the last of the patients to be called.

I changed into a gown, put my clothes into the bag for Paul to take, and was directed to a wheelchair.  While one nurse put surgical booties on my feet, another put a cap on my head and before I knew it I was being wheeled to the operating room.  They asked if I had ever had any reaction to anesthesia, then put in the IV and explained that they were going to give me something to relax and a local anesthetic.  The next thing I remember is waking up in the recovery room as a nurse gave me an injection for pain that I didn’t even know I had.

A short time later, I changed into my clothes and Paul was given a prescription for my pain medication and an appointment slip for a post-op appointment with my surgeon.  Less than two hours after my name had been called, I was in a wheel chair heading for our car, after being instructed to go home and sleep for the rest of the day.  I could do that!  The only negative I have to report is that the prescription I was written was for Tylenol with Codeine which I had told them I was allergic to.  But we had other pain pills at home if needed, so no problema.

The Biopsy

Since we had opted to have the biopsy done at the private lab, as we were leaving Ambulatory Surgery, Paul was handed my biopsy specimen and the accompanying paperwork.  We drove across the street to the lab where Paul took in the specimen and paid for the lab work…a total of 18,000 colones (about $35).

Saturday, June 26th, Day 47:  I’m healing from surgery well.  The incision is neat and clean, and though it is still tender, I have very little pain.  For the last two days I’ve been taking only Ibuprofen for pain and while I’m still taking it easy, I have pretty much returned to my day to day life.  I’m trying to stay busy and focused on the positive instead of worrying about the biopsy results.


While this is the end of my detailed report, I was referred to another specialist for consultation.  We were sent to Hospital Mexico to make an appointment to see an “Infectologist.”  Over the next three months, we made half a dozen trips to Hospital Mexico for appointments with the Infectologist, additional blood work, another ultrasound, and another biopsy.

6/19/11 Note: Thankfully, the results of all of the tests, in the end, showed nothing serious.  I was put on medication for three weeks, after which  I was given a clean bill of health. It is now one year later and I have had no further symptoms.

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