More Healthcare, Better News

(Continued from previous post)

On Wednesday I duly fasted and then headed to the clinic. I immediately saw the cardiologist, Dr. Salas, who reviewed my current health and family history. He took one look at my previous ECG and discarded it, saying that device was notoriously inexact. He even showed me on the computer print out where it said left ventricle when the data it showed as abnormal was about the right side of my heart.  He told me based on my physical condition, he really doubted I had any heart issue, but he had his own ECG machine with him, so he wired me up and ran the test.  He said it looked very normal, with just one reading slightly “off.” He suggested I come up to the hospital on Monday for a stress test, to put the issue to rest. I agreed, and he reiterated he felt confident the test would find nothing.

Next I popped into the surgeon’s office, who gave me another ultrasound. Sure enough, you could see my gallbladder very clearly. It is supposed to be a long oval; mine looked like a pair of connected golf balls. The surgeon told me this was probably a condition I was born with, but the small connection between the two parts of my gallbladder was probably closing from the gunk (my word) that goes through your gallbladder. This was causing the inflammation and other results noted in my blood tests. He said he has seen this condition many times, and most such patients eventually have their gallbladder removed.  He said I could wait until I have severe pain, or I could just have laparoscopic surgery anytime.  I scheduled the surgery and went home.

It didn’t take long for doubts to set in. I was so relieved by the cardiologist’s demeanor I probably would have agreed to a prefrontal lobotomy. Then I started to research gallbladder surgery, and I learned it is controversial NOB, as so many are being performed.  Most gallbladder removal is related to gallstones, which are very painful, but could be treated by preventive measures and lifestyle changes. I had no physical symptoms, just blood work and an ultrasound showing an apparently congenital condition. No one had suggested any diet or lifestyles changes. While the laparoscopic surgery is fairly routine, it is still surgery with a potential for complications. Friends reminded me that doctors here are used to older patients with adequate resources, so there is a tendency to over test and quickly resort to surgery.

I e-mailed my surgeon and asked for a written diagnosis so I could get a second opinion via my insurance, and cancelled my surgery. I will send a detailed e-mail to the Cleveland Clinic, which has a program to give second opinions on surgery for my insurance program.

On Monday, I headed to Guadalajara for my stress test. At the Angeles del Carmen hospital, I met with a cardio technician (Carlos) and a nurse (Edna) who would administer a sonogram and then a stress test induced by Douramine.  Basically they hook you up for a sonogram and an ECG, then administer a stimulant through an IV which causes your heart to accelerate up to your maximum heart rate. They monitor your vitals throughout, and constantly ask you to describe anything you feel. It was quite odd to feel one’s heart beating rapidly, without feeling the need to breathe quickly or pant, and while laying completely still.  Other than that, I felt fine. It took about 30 minutes total time, and cost 5500 MXP (about $300 USD).

After they gave me a decelerant to get my heart rate back down, I went back to the waiting room. Carlos came out and handed me a portfolio with written reports on all my heart data, an annotated ECG chart, and a DVD with all the numeric and visual data (in case I want to entertain my friends?). I went back to Dr. Salas office, where he reviewed the data. He said my heart is perfectly normal! The unusual result that the earlier ECGs showed is something my heart consistently does, so while it is not textbook, it is normal for me.  In my records, I had found another stress test done on me at National War College 20 years ago, and when I showed that to the Doctor, he pointed out even that result was consistent with the current ones. He told me to cut back on bad cholesterol, improve the good type, or he will prescribe statins for me. Other than that, all good.

So in the course of a single week, I went from feeling fine/eating whatever, to sick heart/bad gallbladder, to questionable heart/gallbladder, and back to healthy heart/need better diet. It was quite a ride, and a great dry run for dealing with doctors and hospitals in a foreign land, which is a major expat challenge. Lessons learned: be an educated patient, and research whatever your diagnosis is. Ask questions! Know what the doctors in your area are used to; it affects what they see and how they respond. There is an old adage for medical diagnosis: “when you hear hoofbeats, look for horses, not zebras.” It means look for usual causes first, not unusual ones. But what your doctor thinks is normal will be influenced by where they are and type of patients they see.

Sorry for the long post(s) and the unusual delay, but as you can see, I have been busy. Thanks for all the thoughts and prayers!


The Challenge of Healthcare (and then some!)

So you decide to move to Mexico for the healthy living, but you know that it requires more than exercise, good eating habits, moderation in drink, and adequate rest. It requires good preventive medical care, and if needed, good emergency care. We have been here a few months, so it was time to get started on picking a doctor, dentist, etc.

Dra Candy on the right

So the first thing we needed to find was a dentist. We heard good things from other expats about Doctora Candy Ugalde who has a small practice in our town…yes, I know, a dentist named Candy. Anyway, we made an appointment about a week out, and went in for an exam and cleaning. The office was clean with all the usual modern equipment, the staff bilingual and very friendly. We were seen on-time, and the visit lasted about 30 minutes. We did not receive any pressure to get x-rays or

Note the open doors…

whitening. My dentist, Juan, is Candy’s brother, and he said I will eventually need to get an x-ray, but no rush; when I asked about a whitening, he told me about a discount they are offering, but that was it. Total cost for exam and cleaning for two people: 600 pesos (a little over $30 US dollars).  You can see why some expats bring their grandchildren down for dental (orthodontia) tourism. Overall experience: very good.

Before I get to medical care, first I need to explain something about our health care situation that makes us different from the typical expat. Based on my federal service, we have excellent health insurance, based on the US Foreign Service Benefit Plan.  It is one of the thousand or so insurance programs offered by the US government to its employees, and it continues to cover us in retirement.  This program was initially developed to support US foreign service personnel stationed overseas. As such, it is very familiar in dealing with foreign languages, foreign currencies, and working with customers anywhere in the world. When overseas, the program works on a reimbursement basis (100% for preventive, emergency, and inpatient services, 90% for office visits, surgery, and outpatient services), with all doctors and healthcare providers outside the US considered “in-network.”  Deductible of $300 USD each per year. So while we are responsible for paying upfront for care, our health insurance is set up to immediately reimburse us via electronic document submission and direct deposit.

We decided we needed emergency coverage when we are travelling around Mexico, or around the world. Our Foreign Service Plan continues to cover us in these instances, but we wanted coverage that would give us the option to be medically evacuated at our own request (this last phrase is important). Most insurance, even emergency travel insurance, only approves medical evacuation when it is medically necessary, which is a decision of the doctor and the insurer, not you.  We wanted a service which left that decision up to us. We signed up with SkyMed, which specializes in coverage for expats, covers our medical stabilization onsite in the event of a medical emergency, and leaves the decision to evacuate up to us. Many expats here in Mexico sign up for such coverage, so that in the event of a very serious condition, they can be evacuated back to the States to get care.  Here’s where we differ: we got this coverage so we can be brought back to (drum roll) Guadalajara.  We feel the care here in Mexico is so good, this is to where we would want to be evacuated, if we got sick or hurt out traveling in the wider world.

Nobody ever closes the door around here

For our family doctor, we chose Doctora Lupita at Integrity Medical Clinic. We had some false starts here. First, we made an appointment one day for the next morning, arrived, and found no record of the phone call or appointment we made the day before. The office called to postpone our second appointment, because the Doctora was having emergency dental surgery (ouch). When we were finally seen, we each had a nice office call with the Doctora, who ordered a standard suite of blood tests. We had these done at the lab across the street, and got the results by e-mail later the same day. Costs were 400 MXP each for the office visits, and a total of 2500 MXP for the lab work, or a total of approximately $230 USD for both of us.

We scheduled to meet back with Dra. Lupita to review our results, and here is where things got interesting, as they say. Judy’s review went perfect, with all normal results across the board.  I knew I had a few lab results which were out of the normal ranges, but the trouble started as soon as the nurse came to take my vitals. She took my blood pressure/pulse four times, using two different machines. Any time the nurse asks you “are you having chest pain?” that is NOT a good sign. Then she asked the Doctora to come in and do it again. I felt fine: thirsty, as I had salty foods for both breakfast and lunch, and I had worked out at the gym for 90 minutes before lunch, but otherwise great.

The Doctora said my pulse was racing (over 100 bpm), and she wanted to do a ECG right there and then. They brought the cart in and hooked me up; a few minutes later, she shared my results, indicating left ventricular distress, possible a blockage. She said she wanted me to see the cardiologist in her clinic on Wednesday (two days hence) for another ECG and consult. Oh, and the lab results said I probably had a gallstone; her ultrasound could not confirm it, since I had just eaten lunch, so she wanted me to fast on Wednesday and she would have a surgeon follow up on that, too.

To say I was shocked would be a severe understatement; in shock would probably be spot on! Those who know me know I was a lifelong, daily runner, in very good shape, and rarely had so much as a headache. Since we arrived in Mexico, I even lost a few pounds, took up an every-other-day weightlifting/stretching/stationary bike routine and hiked once a week up the mountains. I never felt better. I just could not square the results staring me in the face with how I felt. I had 48 hours to kill until the cardiologist visit, so I dug up my old records and took to the internet.

First I learned that gallstones and even a ventricular irregularity could be asymptomatic; meaning feeling fine was not out of the ordinary. Gallstones, although painful, looked like the lesser concern: some never end up causing pain, and surgery to remove the gallbladder is practically routine. So I decided to focus on my heart’s ECG results. Amazing what you can find on the internet: full descriptions of how to read one and what it means in laymen’s terms.

Probably the most interesting thing I learned was that an irregular ECG could result from environmental conditions, such as an electrolyte imbalance.  I noticed after I returned home from the Doctora’s office that I was very dehydrated, and Doctora Lupita mentioned that some newcomers have poor ECG results due to their heart’s difficulty in acclimatizing to the elevation here (5200 feet). I hung my hopes on this slender reed and  prepared to see the cardiologist and surgeon on Wednesday.

To Be Continued…


Goin’ Mo-bile!

A musical interlude, before we commence the blogging:

I know I am too old for teenage rebellion, but there is something about getting a new vehicle which just requires dipping into The Who’s “Who’s Next” album for a golden oldie.

We spent the last several weeks investigating our automobile options. We knew we wanted a new car, as my Toyota FJ is 11 years old, can not be nationalized for Mexico (damn that NAFTA), and is a hot deal on the stateside resale scene.

The new-car buying experience is similar between Mexico and the States. You work with dealers, in big showrooms with lots of salesmen, and they offer a standard suite of models with trim/option packages. So far so good. Now for the differences.

New car prices in Mexico are set by the manufacturer on a monthly basis and are uniform across the country. No haggling, no imaginary MSRP, no “INSANE” labor day sales. The only way you can change the total price is by varying the options or by using dealer provided financing (which is relatively new here). This is nice, since we didn’t need to wonder whether the dealer across town had a better deal.

At least in our area, the dealers were all in Guadalajara. In the States, it seems like every small town has a few car dealerships, who are often big fish in the local business community.  Does not seem to be the case here. And that’s important, because in Mexico, when they say “you should use the dealer for all maintenance”, what they mean is “…if you want to maintain your warranty.” That’s right, any unauthorized (i.e., non-dealer) maintenance, or any missed maintenance, VOIDS your warranty.

What happens when the grass is greener on the other side of the road?

Now you may think that the warranty is not a big deal, but maintenance is a major factor in your Mexico driving experience. Roads here vary between normal pavement to cobblestones to dirt streets, often with massive potholes, accompanied by roadside livestock, cyclists and mopeds which pass on all sides, and of course, random pedestrians. Even if you are very alert, you’ll face the ultimate Mexican driving challenge: the topé.


Can you see the bump? ‘Cuz it is there!

Topés are a cross between speed bumps and the Czech Hedgehog. In place of frequent police radar traps,  these silent sentries pop up everywhere to slow you down. Sometimes they are a series of rumble-strips on steroids, or metal bumps which rattle your frame, and the always popular undercarriage scraping raised platform.  Sometimes they are foreshadowed by warning signs, sometimes not. Sometimes old, worn

Where ya’ gonna go now, ranger?

topés are left in place, and they no longer work, but you don’t know that! In general, the poor roads, erratic traffic, and topés = double your maintenance costs.

Sorry, topés brought on a rant, back to cars: dealers here don’t seem to be the cutthroat experience of the States.  Apparently sales staff are NOT paid on commission, and are not necessarily expert on their product. Just-in-time inventory is not quite.  We went to one Subaru dealer who was selling still new 2016 models because they had not received any 2017 models, and yes, this was as the 2018 models were coming out! When we asked about the turbo option on another car, we received the following answers: yes, no, never, of course, and finally, yes. Yes was correct.

We were looking for an SUV, and preferably a manual transmission with a sunroof.  This is the unicorn of new cars, and we quickly realized we needed to compromise.  Like in the States, manual transmissions are less than 5% of new car sales, and generally not even available on most models. Now if you know me, you know I love my manual transmission, but it was clear that requirement needed to go. Judy had a 2008 Subaru with a continuously variable transmission (CVT), but that really did not satisfy in the acceleration department. We did research, and learned that the CVT’s had become much more responsive; I also ran into Volkswagen’s dual clutch transmission, which intrigued.

We test-drove the Hyundai Creta, Kia Sportage, VW Tiguan, and Honda HRV. We found some models did not have cruise control (?), or lacked a turbo, which we found necessary for automatics. It came down to the Kia and the VW, and we ended up selecting the VW. There was only one left in stock: a special edition Wolfsburg.

Meet my new ride

We were taken on our test-drives and met with the dealer’s/sale staff accompanied by Spencer Shulman, who runs S&S Auto, a local car retailer who also serves as a buying-service for expats. Spencer also completed all the paperwork, helped us transfer money to the dealer (all electronically), got the car registered and plated, and delivered it to us.  He will also assist us getting all the maintenace done. He was also invaluable in explaining how dealerships work here, what is and is not available.

You’ll see us driving our VW with Jalisco plates back in the States sometime. We’ll be passing you, maybe even on the left!

Czech Hedgehog: I hope the Mexican government never learns about these!

Observations on Daily Life II

My second set of observations on expat culture here in Mexico may have as much to do with being retired from Washington DC as anything else. Let me explain.

Washington DC may be the nation’s capital, but it is also the “type A” capital of the world. The DC metro area is full of very highly educated, very dedicated professionals set on making a difference. Everybody is in a big hurry, and few people suffer fools lightly, if at all. Making policy is the name of the game, and it is a competitive business.  There is a degree of insularity which resembles that of a company town, but in the big-city way that New York is a company town for fashion and business, or LA is one for entertainment.

In social situations in DC, I found it generally took about a minute for the “what do you do?” question to come up. Being at a social event was like speed-dating: 30 seconds to make a determination whether the stranger you just met was important or interesting enough to talk to. Even people who retired in the region tended to keep “in the game.” Former officials kept their titles, and were understood to be waiting the next round of administration changes to get back “in the game.”

People really seemed to identify who they were with what they do/did. (Note: I am told by friends from NY and LA it is the same there…sigh)

Fast forward to retirement and move 2400 miles southwest.

This picture has nothing to do with this topic, but I liked the view of Ajijic

Here, I know how many kids/grandkids people have, where they have traveled, what pets they have, or where their favorite seafood restaurant is. At most, I hear something like I was a teacher, or a banker, but rarely any details. There are a few folks who take “border promotions,” meaning they now claim a more prestigious job title than they actually had.  But in general, nobody cares. Partly that’s because what you used to be is irrelevant to your identity as an expat. Partly it is because our (collective) circumstances are so different, what we each have the most in-common is our commitment to live the expat lifestyle. That first conversation between new expat friends is inevitably about something you like to do.

Unlike the increasing trend in the States to live among like-minded people, expats end up being thrown together socially, if not literally.  If you live in a gated community, there might be some less mixing, but the property costs may be low enough that it is still not as extreme as NOB. If you live out among the locals, you’ll quickly notice that most properties have a high wall, and behind that could be an enormous hacienda or a series of tents, all in the same neighborhood!

Out socially, expats do tend to flock to certain restaurants and bars, but not segregated in any way. As an expat, you’ll acquire friends from all political stripes, from anarchist-to-nationalist. You’ll meet libertines, libertarians, librarians and Rotarians. While most of these folks have settled views that aren’t amenable to change, the fact we are all strangers-in-a-strange-land makes everyone just a little more accepting. Oh, if you want a debate, you can get one on any topic, but there’s a sense that you don’t push arguments too far here: no sense “harshing the mellow” in paradise.

I would like to think being among the Mexican people has something to do with it, too. They are among the most easy-going, friendly, and welcoming people on the planet, and that has to rub off on the expats. Even with all the vitriol during and after the recent US election, which offended the Mexican people’s pride, I have not heard a harsh word directed at the expats. As one local told me, “we (Mexicans) are used to crazy people in charge, you gringos not so much.”