Wednesday, January 30, 2013

Mets day 293 - Neoadjuvant chemo + 1 year: lessons and advice

One year ago today I was starting my first neoadjuvant chemotherapy session.  Neoadjuvant means chemo before having surgery to cut out the cancer.  Neoadjuvant chemo is not a cure, but is a protective measure to reduce the odds that the cancer that should have been removed via TURBT will grow and spread.

That first day of my neoadjuvant chemo took more than 7 hours.  I remember blogging in real time about it, and being impatient because the GW cancer center was taking so long to poison me.  I did three complete GemCis rounds of chemo, then had a series of scans in mid-April that showed that the chemo had failed.  The bladder tumor that had been removed in two TURBT's on December 1, 2011 and January 5, 2012 had aggressively returned in less than 4 months, larger and more extensive than before.

With the benefit of 20/20 hindsight, because my cancer was the most aggressive form, with micropapillary features and tendrils, I now believe that I should not have had neoadjuvant chemotherapy.  Instead, I should  have had my bladder and prostate removed in January 2012.  The decision to proceed with neoadjuvant chemo was made by relying on the recommendations of three different sets of doctors - those at GW, Johns Hopkins, and Harvard, as well as my review of the literature that suggested that patients with bladder cancer who had neoadjuvant chemo had a 15-20% better chance of long-term survival than those who did not.  What the studies did not show, and what I feel the doctors did not discuss adequately with me, was whether those statistics were true for those with micropapillary carcinomas.  It was not until I was deep into my third round of chemo that I was alerted by a fellow bladder cancer survivor to the grim facts of the very high mortality rate of patients with micropapillary bladder cancer and who waited to have the bladder removed. 

The scans in December 2011 did not suggest that my cancer had metastatized through the bladder wall and into my lymph nodes.  The scans in April 2012 suggested that it had, and post-pathology surgery confirmed that 12 nodes outside of the bladder were positive.  If I had the surgery in January 2012, instead of hoping for the prophylactic effect of the neoadjuvant chemo, then it is far more likely that the cancer would have been contained to my bladder, and completely removed with surgery.  I might still be having the same issues with the nighttime incontinence, but the risk of metastatic cancer recurrence would have been much lower.

I write this not out of any bitterness or anger, but instead for insight to future readers who are going through the same thing.  I believed that the decision to start neoadjuvant chemo was correct at the time, based upon what I was being told and had read.  Generally speaking, neoadjuvant chemo may well be the right treatment for many bladder cancer patients.  But future patients should consider the following:

What is the staging?  The higher the staging, the more serious the cancer is, and the faster you want to move.  T2 or higher means that the bladder must go.  T1, maybe.  Ta and CIS, probably not. 

Is the tumor localized in only one place, or are there multiple tumors?  (I had nearly a dozen.)  The more tumors, then worse it is.  A bladder with multiple tumors is hopelessly compromised.  Get over any thought of holding onto that diseased organ, and get rid of it.  The sooner, the better.   By contrast, it may be possible to save a bladder with only a single low-grade tumor.

Des the cancer have micropapillary features, or tendrils, suggesting that it is highly aggressive? If so, moving quickly to get it out might be best.  Note than many pathologists and even some urologic oncologists are not trained to identify micropapillary features, as they occur in less than 2% of all bladder cancers.  Asking for a second opinion of the TURBT slides is a good idea.

What are your co-morbidities or other complications?  If you are a candidate for RCP (radical cystoprostatectomy, the surgery that removes the bladder and prostate), and it is indicated, then don't delay. A delay of only a few months can be the difference between keeping the cancer localized in the organ, and thereby having a high chance of recovery, or having the cancer spread, and dramatically reducing the odds of survival.

Good  luck!  

Tuesday, January 29, 2013

Mets Day 292 - No artifical sphincter for me

Today I spoke with Dr. Greg Bales of the University of Chicago.  We had been trading calls for a couple of days.  He's the incontinence specialist who works with Gray Steinberg.  Dr. Bales was familiar with my history, and sympathized how nocturnal incontinence can be a real challenging problem, especially with neobladder patients. He said that having sleep disruption in the way that I have been suffering is relatively uncommon.  He said that most men with nocturnal incontinence may wake up but are able to go back to sleep and get adequate rest,unlike what I'v ebeen dealing with fo the past 7 months.  

We discussed my options.  To my surprise, he said that, because I am usually continent during the day, he does not think that I am a candidate for an artificial sphincter.  Those are usually for patients that have no control on all days.  My daytime continence suggests that my pelvic floor is acting as a sufficient sphincter.  The function of the sphincter can be assessed by the urodynamic assessment.  If the assessment shows that the sphincter isn’t working properly, then I may be a candidate for an artificial sphincter.  But because an artificial sphincter has its own complications and risks, and because I am dry during the day, based upon the information he has, he would not recommend doing the surgery. 

He recommends that I have a urodynamic assessment locally.  He does not agree with Mark Schoenberg that I have to go to Chicago to have this done.  He also recommended that I create another voiding diary, recording my intake and output.  I did one in June of 2012, and another in July of 2012, and so I know the drill. 


I asked him what my options there were, since he did not recommend an artificial sphincter.  He said that the most common thing is that patients just wear pads and deal with it.  But most patients are not like me, who wake up and can't go back to sleep when they leak.  He said that some patients try self-catheterizing each night (been there, done that); others try leaving the catheter in overnight (done that with Foleys); others have used condom catheters (tried that, hated it). For anything else, he said I should work with a urologist who specializes in male nocturnal incontinence.   He recommended a specialist associated with the University of Maryland, and offered to make the introduction.  Looks like I'll continue my search for a solution.  No easy fixes, I'm afraid. 




Wednesday, January 23, 2013

Mets Day 286 - Of Artificial Sphincters

In the past few days I've been exchanging emails with Gary Steinberg, the Chicago surgeon who did my RCP and neobladder last year.  I emailed him the following:

"I’d welcome your input re my options. I continue to have nighttime incontinence, with its attendant sleep deprivation. On Sept, 14, 2012, Trinity Bivalacqua stripped away some of the scar tissue in the bladder neck. Per his instructions, I continued with CIC 2x daily. On Nov. 21, you advised me to continue with CIC, checking for overflow incontinence. I catheterize before going to bed when I feel that I am not able to void completely, but usually have less than 50 ml left. The times that I’ve catheterized in the middle of the night after leaking, I usually have less than 150 ml, so my leaking does not appear to be overflow incontinence. Recently, I’ve noticed that I’ve had to strain more when voiding. My flow usually is weak and sporadic.  My questions are:

1. Should I be doing any kind of physical therapy to help with the nighttime incontinence? If so, what, and with whom?
2. Should I be evaluated to see if there is additional scar tissue or another physical problem that can be corrected to help reduce the nighttime incontinence? Should you do that, or should I have my local urologist do that?
3. I leak at night, even after voiding. When I leak, I wake up and find it difficult to go back to sleep. Is there anything that can be done to help me be less sensitive to that, apart from taking Ambien or Lunesta?
4. What options are there to help me with the incontinence? David Pulver of BCAN mentioned a sphincter valve. Should I consider that? Or should I consider having the neobladder changed to an IC?
5. Should I schedule an appointment with you? Obviously, flying out there is not convenient for me, but I’ll do whatever is appropriate to try to address this.
6. Are you aware of any other clinical trials or other therapies I should be doing to minimize the risk of metastization?"

 He responded as follows:

"Thank you for your note and follow-up. Your nocturnal enuresis is problematic. From what you describe it does not sound like overflow incontinence. If you are able to catheterize yourself then I think that a bladder neck contracture is unlikely. Medications such as Ditropan or Detrol may potentially help increase your bladder capacity as well as decrease any bladder hyperactivity you may be experiencing which may be a cause of your nighttime leakage. However, these medications may cause constipation and make it more difficult for you to void. Other causes of nocturnal enuresis include loss of neurologic control of the external sphincter."

"I think that your options include a urodynamic assessment of your neobladder to assess capacity, compliance and pressures to see if we can make a diagnosis to direct therapy. We have implanted artificial sphincters in some patients as well.  Please let me know if you would like to come to Chicago for the evaluation and we will arrange it for you."

I also exchanged emails with Gary Schoenberg at Hopkins, and he also recommends that I go back and see Dr. Steinberg.  Apparently it's best to have the surgeon who built the neobladder mess around with it.  So another trip to Chicago might be in my near future.  What I need to find out is whether I would have the assessment done and, if it suggested that an artificial sphincter is appropriate, have that implanted during the same trip, or have different trips.  

Here is some information on artificial sphincters:

A YouTube video with a patient experience and illustrations is here.

The WebMD article is here.

The Medscape link is here


Bottom line:  An artificial sphincter can help, but it's not perfect.  But aside from my wife, what is? 



 



Monday, January 21, 2013

Mets Day 284 - Part-time work

For the past couple of weeks, I have been talking with my firm's managing partner about the terms of my employment for 2013.  The firm has been most generous in 2012, providing my with full pay for the year, even though I was out for many months, and working at less than full capacity for much of the rest of the year.  I know that I could not work 100% while I continue to deal with my cancer and the complications from the treatment, but I did not want to completely stop working, for many reasons:  (1) I wanted the hope that I can return to near-normal after I beat this; (2) while I am fighting the good fight, I will still need health insurance for my and my family, and staying affiliated with the firm lets me stay on the firm's group policy; (3) I can still do some legal work, even if it is not full-time; (4) I feel obligations to my clients, even though the amount of time I will be spending will be much reduced; (5) there is a psychological benefit to keeping my mind engaged in my profession: and (6) the extra money helps. 

My firm's management was most flexible and supportive of these goals, and was willing to consider any proposal that would help me with my objectives.  I wanted to be fair to the firm that has given me so much support.  Last week, I proposed, and management agreed, that I receive a fixed annual compensation for 2013 of about 15% of my 2012 compensation, with true-up/bonus provisions based upon billable hours and income from certain client matters, and the ability to return to full participation in the partnership any time that my health allows. I am satisfied with this arrangement, and it seems to be fair all around. 

I expect that, for the near future, I will be billing only 20-30 hours per month.  I don't yet know how often I will be going into the office, as opposed to working from home.  Each day is determined in large part by how poorly I slept the night before.  I've learned that, even if I feel like I got a relatively decent night's sleep (the key being relative -- 4 or 5 hours, as opposed to 7 or 8 before surgery), then I might have a good day.  Less than that, bleah.  And even on a "good" day, I tend to fade by the afternoon.  Nighttime activities are even more difficult. 

I am tentatively exploring my newfound freedom to define my days.  Over the next couple of months, I will see a pattern emerging in this new part-time schedule.  I'm not yet sure what it will be, however.  It's a strange thing to not have either the expectation that I will go into work for a full day each day, or to even have an aspiration to do so.  I've been doing that for 25 years, and before that, it was school or other full-time activities that in many ways defined my day.  Instead of the tyranny of the billable hour, my life activities are more influenced by how leaky my neobladder has been, and how much sleep I can get. I have a number of things on my to-do list, but so far I have shown remarkably little interest.  I need to figure out how I can find motivation to do things even when my body wants more rest. 

Tuesday, January 15, 2013

Mets Day 277 - On Estate Planning

When I was diagnosed with metastatic cancer on May 15, 2012, I understood that the cancer likely would be my cause of death.  I already had read and understood that there was a 88-90% chance that urothelial cancer in the lymphatic system would spread, most likely to my spine, lungs, or liver, and that I would not live longer that 5 years.  Dr. Steinberg acknowledged those statistics when he discussed the pathology report with us on May 15, but also emphasized that there was no way of knowing whether, when, or what the disease would do to my body.  The doctors at GW, Hopkins, Fox Chase, and NIH, all have told me the same thing.  The odds are not in my favor, there is no established medical treatment for microscopic metastatic urothelial cancer, but I'm young, I had surgery very quickly after the chemo failed and the cancer had metasized, and a lot of lymph notes were removed.  The common theme of the doctors was that I should live my life as best I can, and focus on the joy in each day.  Death comes to all sooner or later.  In my case, it's likely to be sooner than later.  I am reconciled to these facts. 

One might expect that, in the face of these facts, that I would be motivated to revisit my estate planning, look at my will and trusts, and pull together all of my financial information.  While I have done pieces of that, I have not completed all that I should.  Whether I've been focused on my recovery from surgery, or returning to work, or pulling together information for the insurance companies, or planning our family vacation, or just plain avoidance, I have not been eager to work on estate planning. 

This morning, Jennifer and I sat in the hot tub and talked for about an hour about financial issues, real estate, and touched on estate planning.  We decided that it made sense to put our lake house up for rent this summer, and also explore the possibility of selling it.  Since I have decided to live life at an accelerated pace, doing so likely will involve more travel and other experiences different from going to the lake house.  The lake house has served its purpose for a decade; time to let others enjoy it.  We also talked about whether we should sell our Great Falls house, and decided that we should not do so in the near future.  After the nest empties in 2016 or so, we (or Jennifer, if I'm gone) likely will downsize.  We talked about whether Jennifer would want to buy elsewhere, or rotate around different parts of the country, renting month to month while visiting family, especially while the kids decide where they will settle.  We also discussed insurance, our current financial status, my negotiations with my law form regarding 2013 compensation, and several other issues.   

With that conversation fresh on my mind, I read a New York Times story that reinforced what Jennifer and I talked about this morning.  The story talks about a woman in Seattle whose husband was killed in a biking accident, and how she had to struggle to pull together all of her family's financial information.  She started a web site that collected all of her experiences and lessons learned.  Her web site also has a link to a useful Wall Street Journal list of 25 documents you need before your death, and also to a BBC booklet, Planning a Good Death.  After reviewing all of this stuff, I'm slightly more motivated than before to revisit my estate planning. 

For starters, I'll list what I've done so far, then I'll list what I need to do:

Estate planning already done for Jennifer and myself, in 2000:
Signed will
Signed revokable trust

Signed irrovokable life insurance trust
Signed advanced medical directive
Signed durable power of attorney
Lawyer's letters of instruction

More recent estate planning done in the past 6 months:
Transfer to Jennifer of all custodial accounts, including education savings accounts
Compilation of all financial information, including statements for all accounts, revenue sources, bills paid, and login information and passwords

Estate planning I still need to do:
Have the 2000 wills and trusts and other documents reviewed and updated as appropriate
Make sure all property is properly titled
Better organize recent financial records, statements, etc.
Continue to educate Jennifer and kids on financial information
Write letters of instruction

Other legacy stuff to do before I die:
Personal letters to family members
Organize personal history, journals, pictures, videos, etc.

I'm sure there will be other things I'll think of as I go along, but this gives me a good idea of what I need to do now. 


Monday, January 14, 2013

Mets Day 276 - sleepless again

The past two nights have been pretty short on sleep.  The bedtime routines were the same as usual - take the Lunesta and baby aspirin, void the neobladder as much as possible, including occasionally catheterizing, brush teeth, put on the Depends or the absorbency pad, pray with Jennifer, then read until I get too tired to keep my eyes open, get up, void one more time, then go to sleep.  The trouble is, I didn't actually fall asleep.  I tossed and turned, kept waking up, went to the bathroom several times, tried to get back to sleep, dozed a bit, but could not get into any rhythm.  Ok, every few nights that happens.  I sleptwalked through Sunday, going to church then trying to watch the playoff games but not really into them.

Sunday night I knew that I was so tired that sleep would not be a problem.  Jennifer has driven up to Canaan Valley for an overnight visit with friends, so I had the bed to myself.  Same bedtime routine (only earlier -- this time, lights off just pas 11 pm).  I did go to sleep, but at 2 am was jolted awake by a wet patch on the bed.  My absorbent pad in my underwear had shifted and failed to perform its purpose.  I sat in the hot tub, put on a Depends, put a towel under the wet sheet, and rolled over to Jennifer's side.  Further sleep eluded me. Toss, turn, up, down, nothing was effective.  Maybe I should have read the Book of Mormon:  Chloroform in print, Mark Twain called it.  But it usually doesn't have that effect on me.  In any event, by the time the sun rose. I was already exhausted.  Monday wasn't a productive day. 

It's been a while since I've had two back-to-back nights that were so bad.  Usually, I can get at least 4 hours of consecutive sleep every other night, and sometimes I can get as much as 5 or even 6 hours in a night.  This past weekend was a reminder of how fragile my physical state really is. 

Wednesday, January 9, 2013

Mets Day 271 - Plans for 2013

My plans for the new year are starting to come into focus.  The variables are falling into place.

One significant unknown was with regard to disability benefits.  It now appears that I will be able to receive the benefits of at least some of my private disability insurance policies.  Over the past 15 years or so, I had purchased and paid premiums with post-tax dollars on five different disability insurance policies:  Three with MassMutual, one with MetLife, and two with Unum.  I collected these policies over my career with two different law firms, and have added coverage from time to time.  The premium cost was not trivial, but I'm now glad that I purchased and maintained those policies.

The three MassMutual Policies, and one Unum policy, were income replacement policies that would pay varying amounts if my ability to maintain my income was compromised due to illness or accident.  The MetLife policy would make payments into a retirement account if my earning ability, and thus my ability to save for retirement, was compromised.  The other Unum policy was for long term home care as needed.  I have had those applications pending for months, some since August 2012, others since early October.  I ended up having to personally collect the medical records and send them to the insurance companies, because either the insurance companies or the docs were slow-walking the records requests.

Upon my return from my vacation with my family, I found that MassMutual had approved my disability applications on all policies I had with them.  They concluded that my 6 month elimination period had been met, and sent me a check to cover the first two months of benefits.  Future benefits will be direct deposited into my account. 

Likewise, MetLife has approved the payment of retirement benefits under their policy. Those benefits will be made into an irrevocable trust, and I will have the ability to direct the investment, sort of like an IRA. Those benefits will become available at age 65 or to my estate upon my death, whichever occurs first. 

I am still awaiting a decision by Unum on its two different policies.  If approved, one will add to my monthly income replacement benefit, and the other will reimburse me for any needed home health care.  Unum had told me right before I left on vacation that it was going to approve the home benefits claim, but upon my arrival home, I saw a letter from them saying that Unum needed more time to make a decision. 

The income replacement policies have an interesting aspect that directly affects my work plans.  Because they are income replacement policies, they are pro-rated based upon how much I work and am paid by my law firm.  If as a result of my disability my income from my legal practice falls 80% or more, then I am considered totally disabled and will receive 100% of the insurance benefit.  If my income from my law practice falls less than 20% due to my disability, then I am not considered disabled, and not eligible for benefits.  If my law firm income is between 20% and 80% of before, and the loss is due to my disability, then I am partially disabled, and my benefits are pro-rated.  For example, if my law firm income is 50% of pre-disability, then I would get 50% of my benefits.

The total amount of benefits does not equal the amount of earnings I had at the law firm, however. The maximum benefits equal only about 60% of my pre-disability income.  But because I paid for these policies with taxable dollars, all of the benefits are tax-free.  I don't know what my marginal tax rate will be in 2013, but it likely will be at least 25 or 30%, so a dollar in insurance benefits is worth at least $1.25, and probably more, than a dollar in taxable earned income.
 
The curious effect of the way these policies are structured, coupled with the tax consequences, is that I have no economic incentive to work and earn more than 20% of my prior income, unless I will be earning more than 65%.  For example (these are not real numbers, just a hypothetical), if my annual total pre-disability gross earnings was $150,000, and the maximum insurance benefits was $100,000, then if as a result of my disability my earnings were 50% of before (or $75,000 in taxable dollars), the insurance companies would pay 50% of the benefit, for $50,000 in non-taxable dollars.  My total income would be $125,000, of which $50,000 would be tax-free.  But if my post-disability earnings were only 20% (or $30,000 in taxable dollars), then I would receive 100% of disability benefits, or $100,000 in tax-free income.  In that instance, my total income would be $130,000, with $100,000 being tax free.  Thus, working and earning 50% of before provides me with less income than earning working and earning 20%.  I figure that the break-even point is about 65% of pre-disability income.

Of course, my preference is that I would be completely cured and able to work 100%, without any disability.  But as long as I have my continued issues with incontinence, sleep deprivation, the increasing likelihood that I might have another major surgery, coupled with the high statistical likelihood that the cancer will metastasize into untreatable secondary tumors, I do not believe that I will be able to resume anything resembling a normal work schedule, or even something around 50%.  My primary focus is on my physical, emotional, and spiritual health.  I intend to draw upon my disability benefits to provide financial means for me and my family in the meantime. 

Thus, for the near future, my plan is to contribute as I can to my law firm, but billing at a substantially reduced pace.  The firm reports to the insurance company each month the number of hours worked, and how much I am paid, then the insurance company makes its determination of whether a full or pro-rated benefit is paid, then it will make its payment.  I'll keep (and continue to pay for) my health care and other benefits through the firm, and keep the door open to a return in the event that I recover and am able to perform a greater amount of work. 

I also will co-teach my law school class this semester, but would not be surprised if this is my last year teaching.  I simply cannot foretell how I will be feeling a year from now.  As I wrote last month, my planning horizon has been reduced to about a year on a rolling basis, and I am increasingly comfortable with that time line. 

As I ramp down my involvement in my legal practice, I expect to increase my involvement in various community, charitable, and religious organizations.  I especially want to spend more time with my family, both at home and traveling.  I have some specific plans, as well as some vague ideas that will take form in the coming weeks and months. As those plans take shape, I will share them as appropriate. 

Saturday, January 5, 2013

Mets Day 267 - Costa Rica Days 10-15

Tuesday January 1

We greeted the new year by sleeping in.  This was unlike the day before, where I was awoken by loud hooting noises.  I looked out the window and saw a large howler monkey sitting in a tree.  I walked out and saw a family of monkeys, including a mother with an infant clinging to her chest, slowly making their way through the trees, pausing to eat nuts, berries and fruit.  I woke up the kids and watched the monkeys for about a half hour.

They eventually moved on, and the kids went back to bed.  I spoke with Louis, the owner, who said that this was a monkey highway, and he had been careful to leave lots of trees so they could continue to move around.

Anyway, to greet 2013, the kids eventually made their way over to our apartment and finished off the cereal and milk.  We spent another strenuous day going from the beach to the water, to the beach, to the hammocks by the pool, into the pool, back to the hammocks, back to the beach.  The Las Tortugas Hotel pool is 15 feet from the beach, so getting to the hammocks is quite convenient.  The hotel has a large thatched hut holding 6 hammocks and a table and chairs.  There are 17 bats that roost in the rafters of the hammock, and fly out at dusk.

All of us have books, of course:  I have been reading Rough Stone Rolling, a cultural biography of Joseph Smith; Jennifer, Cutting for Stone; Josh, The Hunger Games, Chelsea, A Dublin Student Doctor; Spencer, The 100 Most Important Battles in World History; Kirsten, Candide, and The Hobbit; and Garrett, The Hobbit.

Jennifer and Garrett like walking on the beach and collecting shells, and I expect we'll have quite a bag full by the time we leave.  I'm not so big on shell collecting.

Garrett asked for a surfing lesson, and we found a local dude who gives a 2 hour lesson for $25. Spencer repented of his vow the day before to never surf again and joined the lesson, and they had a good time. Both succeeded in standing up several times.

At various times for the rest of the week, each of the kids would grab a board and try the waves.  The hotel also gave us 2 boogie boards to use, so we could alternate our water amusements. The beach and waves are perfect:  you can stand waist deep in water and wait for a 4 foot roller to come behind you, hop on and enjoy the ride.

We were scheduled to go on a turtle tour tonight, sponsored by the national park.  They take reservations a week or two in advance -- no more than 40 people per evening, they said -- and you show up at the park enhance at dusk and wait to see if the spotters see a leatherback coming ashore to lay her eggs.  If so, they take 15 people per group, and only 2 groups for each turtle.  If you have a number over 30, and all of the first 30 show up, then you have a minimal chance of seeing a turtle.  But there is a 20% no-show rate.  Our 7 were numbers 30-36, but 8 people in the first 30 did not show up, so we would see the first turtle, if one showed.  You pay the $25/person fee only if you get to see a turtle.

While waiting, the park employees narrated a show a slide show explaining how poachers in the 1980s caused a 90%+ drop in today's turtle population in the Pacific. It takes about 20 years for a turtle to reach sexual maturity.  The park was established in 1989 and the employees have been counting how many turtles show up each year.  Last year, only 34 turtles showed up, in contrast to 1990, when over 1800 turtles showed up.  Since egg-laying season lasts about 150 days, we knew there was only a 20% chance a turtle should show up that night.  We waited for about 3.5 hours before the ranger said to go home -- high tide had passed, so no turtles tonight.  So other than feeding the mosquitoes, we didn't see any wildlife. (We signed up for the next night, but were told that we were numbers 46-53, so we didn't even bother checking in.)

Wednesday, January 2

Another sedentary beach day.  The weather has been perfect -- clear skies, high 80's, and a nice breeze.  In the afternoon, Jennifer, Spencer, and I paddled a canoe up the salt water estuary. We saw lots of birds, and Jennifer thought that she spotted a crocodile.  Coming back we were paddling against the tide, and my hands, arms, and back got a workout.  I'm out of shape. (Chelsea: "Round is a shape!").

Since we arrived at the apartments, we have been cooking more and eating out less.  We have cereals and fruit for breakfast, sandwiches and chips for lunch, and for dinner we have had spaghetti, burritos, RUPs, and more.  I've been doing a lot of cooking for dinner, and have been enjoying preparing the food. We usually play lots of family games each night, such as Mao (a variation of Uno, where the winner of the prior round makes up a rule but does not reveal it until it is broken), Bananagrams (a variation of Scrabble), Beananza (another card game), Five Crowns (still another card game), or Pit.  We have a lot of good natured kidding during the games.  Both Jennifer and I can be competitive when playing games, and each of our kids can be likewise.  It can get intense.  

Thursday, January 3

Everyone except Jennifer got picked up for deep sea fishing at 6:45 am.  (Jennifer, who can get seasick, slept in, then walked on the beach and read in the hammock.)  The rest of us were taken to a small port at Playa Flamingo, where the six of us boarded a 31 foot fishing boat.  The captain took us a mile or two out, and two fisherman baited 4-6 lines.  We took turns reeling in whatever hit our lines.  We started off by catching some tuna, each about 2 feet long.

We also caught some red snapper. Josh caught an ugly grouper. We trolled for some bigger fish but nothing was biting.  The fisherman filleted a couple of tuna and cleaned the red snapper.  We had our dinner!  We were back by lunchtime.  It was the first time fishing in open salt after for any of us, and we had a good time.

The rest of the day was spent recovering.  Naps, reading, swimming, beach walks, and surfing by the kids.  That evening, I cooked rice and beans, and fried up the snapper and tuna.  Good stuff.  We played more games and talked and laughed a lot.

Thursday, January 4

Our last day at the beach.  I made French toast for breakfast. No syrup, but butter and powdered sugar did just as well.  We spent a couple of more hours surfing, boogie boarding, walking on the beach, shelling, and getting a few more minutes of hammock time.  Our goal was to be back at the apartments by 11 to shower, pack up, have lunch, then hit the road back to San Jose.  The adults wanted to try to visit the Mormon Temple in San Jose, while the kids caught a movie at the nearby mall.  According to Google, it was about 250 km, or about 4 hours, from Playa Grande to San Jose.  Of course, packing up took long than expected, and we didn't get going until about 1:15 pm.  It was clear driving until we hit the Pan-American Highway, and our pace slowed to a crawl behind a line of semi trucks.  We didn't arrive at our hotel in San Jose until 6:30 pm, too late for the temple. We were all tired of the drive and hungry, so we decided just to have dinner and relax.  I found a nearby place to eat called Soda Tapia -- a Tico version of Johnny Rockets -- and we enjoyed s the first junk food of our trip.

Driving back to the hotel, I could not legally turn where I wanted to, and in trying to make our way back, I got lost.  Of course, we had taken out the GPS and the maps when we emptied the car, so I was driving blind in San Jose.  I was pretty sure I was circling back, but in the dark with no landmarks, and no street signs or addresses, there was no way to be sure.  We finally drove by some police, and Josh jumped out and got directions back -- simple, once we knew the way to go.  Sort of like life.

Saturday, January 5

We had breakfast at the hotel, loaded up, then drove by the LDS temple for a picture.  We then filled up the Montero and returned it.  Despite all of the horror stories I'd read about car rental places ripping you off, the people at Dollar were fine, not worrying about the hole I'd driven in and pushing back the front mud flap, or how we had a layer of sand and grime throughout the car.

Going through airport security, they made Jennifer take out the shells and keep only 4 and through the orders away.  She's still upset about that -- those were her souvenirs!  The security person would not say why, either.  Oh well.

Today is Spencer's birthday, so I gave him the last of my Colones and a mission to spend it all before we got on the plane.  He came back with a t-shirt and a tin of chocolates, which the rest of the family fell upon like ravenous wolves.  I hope he wasn't planning on giving it to his girlfriend.

We connected through San Salvador, and we were on final approach to land when the pilot suddenly made a hard S-turn at full throttle.  We were only about 500 feet above the ground.  I told Jennifer that something had happened on the approach, and that the pilot had bailed.  The pilot kept the full throttle on for another couple of minutes as he climbed back up to about 2000 feet and got back on the groove for another approach.   The senior flight attendant got on the PA and explained that the ground radar at the airport was not working, and that the pilot saw traffic on the runway just as he was about to land, so he aborted.  It was a split-second decision, but was handled very well.

After we deplaned at the San Salvador airport, we were put into another queue to have all of our carry-on luggage subjected to a hand search, then be wanded, and our shoes physically inspected.  The inspector took out every item in my bag -- I was carrying a lot of dirty laundry, and was concerned that some of it might be declared to be a toxic weapon of mass destruction -- but the inspector was more interested in whether my ratcheting tie-down straps were ok.  He also came back to Garrett's solar-powered flashlight three times, as if he never had seen such a thing.  (I could see the wheels turning in his head:  why have a solar-powered flashlight, since you don't need a flashlight in the sun . . .)  Everyone going to IAD was likewise searched, but Josh said that Garrett and I get the most thorough inspection -- his inspector barely looked inside his bag.  It was especially strange since we had already passed security in San Jose.  My guess was that it was more drug-related than security-related.  

All in all, it's been a great vacation.



Tuesday, January 1, 2013

Mets Day 263 - Costa Rica Days 5-9

Costa Rica Days 5-9

Wednesday, December 26

We started our last day in the La Fortuna/Arenal area by splitting up:  Spencer, Garrett and I went canyoneering and rappelling, while the others went browsing around the town looking for souvenirs. The canyoning was good -- we essentially made our way down a narrow ravine with a small stream rushing past. It was narrow enough that we could shimmy and edge our way down without too much difficulty.  About 4 or 5 times, we roped in and rappelled down the waterfall.  One untethered decent ended with a jump and plunge into a 9 foot deep pool that was only 3 feet wide.  The rappels were not too technical; in fact, the longer drops (one over 250 feet) were a couple of controlled drops, then kick back and free slide, trusting the belay to slow our progress.  The hike back out was the most difficult part.

We met up with the others, loaded up the 4x4 with 4 of our bags tied to the roof rack, and headed west over the Continental Divide to Monteverde.  It's about 45 miles as the crow flies, but took nearly 4 hours to get there.  We drove around the scenic shores of Lake Arenal, a large reservoir near the base of the alleged volcano (we never did see it, since it was always shrouded in clouds). We stopped at the German Bakery in Nuevo Arenal, and were stunned when we were charged $30 for 2 bratwursts and a couple of croissants and sodas.  It was the first sign that we were headed to a zone where envy thing was overpriced and underwhelming. In addition, it started to rain steadily as we drove deeper into the mountains.  Before the rain hit, this was a view of the road to Monteverde:
 We would not see the sun again for days.

We rolled into Monteverde around dusk, the last 40 kilometers on a rutted dirt track. The GPS tried to direct us on a detour of more than 60 kilometers in exchange for 20 fewer kilometers of dirt roads, but that would have taken more than an hour longer.  Kirsten was incredulous when I announced that I didn't trust the GPS, shut it off, and turned on a dirt road in the middle of nowhere.  She didn't know that I had studied the maps a good deal before we left on our tip, and again in the days before the drive.  Her questioning me, and the increasing the uncertainty with the rest of the family, made our arrival all the sweeter.

We arrived at Cala Lodge, a small, eco-friendly hotel adjacent to open of the nature preserves.  Each of the rooms was supposed to be capable of sleeping 3. I had emailed the owners and had been assured that, for the kids, that meant 3 different beds.  When we arrived, however, we found that all the rooms had a queen and a singe - three different beds was not an option.  Spencer and Garrett were not about to share bed, so they took one room and Kirsten took the extra bed in our room.  Fortunately, I had packed extra ear plugs to help her block out our happy snoring noises.  She vowed that she will never snore when she's middle aged.  I think that will be as effective as my youthful vow that my children would be respectful of their parents at all times.

We are dinner at the Chocolate Cafe -- how could you go wrong at a place like that, right?  It was very good; in fact, the empanadas were fantastic, and the chocolate was amazingly good.  We learned that they produced all of their chocolate from the local cocoa bean harvest, and gave a daily tour of their chocolate-making operation.  We promised to return.

Thursday, December 27

We rolled out of bed at 6:30 am, eager to see the fabled Cloud Forest Nature Reserve (link here), situated on the Continental Divide.  The moisture from the Pacific Ocean comes rushing up the mountains, cools, and rains almost every day of the year, creating an unusual tropical rain forest in the mountains, surrounded by tall mossy trees and abundant wildlife.  We had read that we should get an early start to see the critters and avoid the afternoon rains.  It was lightly misting as we set out from the entry point.  We decided to hike the circular route around the perimeter of the park.  In the first few hundred yards, we saw a monkey and a coati, and some spectacular vegetation.  This is pretty cool, I thought.  Then it started to rain.  The wind started to blow.  Soon we were slogging through a monsoon.  All the critters went under cover, the fog started to roll in, and it turned into a bad Seattle winter day.  By the halfway point we were wet, tired, and grumpy.  Spencer compared it to walking to Mordor. We eventually made it to the suspended bridge, and got someone to take this photo of our clan during one of the brief breaks from the rain.

After four hours, we made it back to the entry point and proceeded to coat every interior surface of our 4x4 with a muddy layer of grime.  Eh, it's a rental.  (It still smells like a locker room.)  We made our way back to lodge for showers and naps, and decided that the Cloud Forest was a once-in-a-lifetime experience, with the emphasis on once.

The winds rose the rest of the day, and the rain was horizontal at times.  We played a number of family card games, then braved the elements to hunt and gather nuts and berries.  We found good eating at Morphos Restaraunt, then went back to the rooms for more relaxation.  Unfortunately, Chelsea got some stomach bug, which is ironic because she was the one most vigilant about only drinking bottled water (the rest of us had mostly been drinking tap water).

So far, the rest of us were not having any problems.  I was still incontinent at night and waking up when I leak, but the Lunesta helps me get back to sleep.  As long as I take it slow and don't try to do anything too strenuous or analytical, and take regular breaks, I'm usually ok.

Friday, December 28

Montevede is the home of the zip lines, where you are suspended from a cable and glide over or through the trees, and canopy tours, where there are suspended bridges through the tree tops.  Before we left, the kids had been excited about doing the zip lines, and Jennifer wanted to do the canopy tour.  Now that we were here, however, they did not seem as enthusiastic.  Maybe it was the fact that it was raining, and they would not be able to see anything.  We did, however, stumble upon a brochure for one place called Extremo Adventures that offered bungee jumping.  Spencer and Kirsten immediately declared that they would much rather bungee jump than zip line.  Neither had ever been bungee jumping, and both wanted very much to do it.  To my surprise, Garrett also said he wanted to do it.  No one else wanted to do it, so while I was figuring out logistics, a van for the bungee jumping company pulled up to our lodge to pick up some other tourists.  I gave Spencer my credit card and some cash and they jumped in the van.  My parting words to Garrett was what he wanted on his epitaph. He laughed nervously.

While my three younger kids were jumping off platforms hundreds of feet in the air, the rest of us went to the orchid gardens next to Morphos.  There was no one at the entrance, and after waiting a bit, we walked through.  Chelsea and I saw two orchids, and thought, that's it?  One of the workers eventually found us and explained that they gave a guided tour and provided magnifying glasses to examine the orchids.  Jennifer and Josh decided to go for it but Chelsea and I decided we'd rather do something else.  We walked around the small town of St. Elena -- a small tourist town formed on a triangle of streets. We browsed some shops, then found a bookstore and passed the time.  Everyone was happy.

When we met up again with Jennifer and Josh, they said how they thought the orchids were amazing. They took lots of pictures using the macro, so the orchids look larger than the head of a pin.  I'm glad they liked it.  Then Spencer called, and said that they had all survived the bungee jumping, and since the ride back wasn't several hours, could we get them?  So we loaded up and fund our way out to Extremo Adventures, where they all had silly grins and we're gushing about the insane thing that they had just done.  A platform was suspended over a ravine with a drop over over 460 feet.  They wrap the bungee cords around your feet, and also secure you to a climbing harness for safety, and you stand at the edge as they call 3-2-1-GO!  Spencer was first, and later said that he got kind of shaky after once the adrenaline wore off and he though about what he'd done.  Garrett went second, and did not jump an the GO! (he said he was waiting for the wind to be "just right").  He eventually took the plunge.  Kirsten was last, and was whooping the whole way down.  All of the jumps were recorded from multiple angles on video (including a helmet cam) and Spencer bought the DVD.  I have not seen it yet because all I brought was the iPad.  Maybe I'll figure out how to add a link after our return.  Spencer also said that the forms stated that no one under age 18 would be permitted to bungee jump, which should have disqualified  Kirsten and Garrett, but they were happy to take the money and let them do it.  Pura vida!

After picking up the kids, we drove up to Selvatura Park, a privately-operated place with zip lines, canopy tours, a snakes and reptile house, and insect collection, a butterfly house, etc.  I thought we'd do a number of activities there, but when we got there it was raining, windy, and cold.  The kids chose to go through the reptile house, since it was enclosed and out of the wind and rain.  Everyone passed on the opportunity to ride the zip lines or walk through the suspended bridges for the canopy tour.  We saw the critters, then bounced off to find some lunch.  After, some of us took naps while others went off to find hummingbirds.  We have pictures of the kids with hummingbirds perched on their fingers while they sip nectar.

None of the girls were hungry for dinner, so I went with the rest of the boys to a pizza joint, where we sat by a wall adorned with a poster for a 1987 Paris exhibit of impressionist painters, and were entertained by a family from Texas singing country songs from the 1970s, karaoke style.  Some of the notes were actually on key, too.  Garrett could not understand why the owner would let them sing so badly.  I told him to roll with it. At least the pizza was better than the music.

Saturday, December 29

When I was planning out the agenda for this trip, I initially planned on staying only 2 nights in Monteverde.  After reading about all of the amazing things there, I added a third day.  I should have stuck with my original plan.  Of course, we had no control over the weather, but Monteverde was not what we had hoped or expected.  Maybe it's the fact that Moneteverdians are so hyper eco-aware that everyone is forbidden from flushing their toilet paper; instead, you must us a separate bucket.  Why not just use bio-degradable toilet paper instead of adding to a landfill?  Anyway, I was ready to leave for the beach on Friday, but our reservations were made and there was little flexibility in the high season.

On Saturday morning we all slept in until 8:30 am or so, packed up, then decided to try the butterfly house. We'd stopped at two others but had been told that we would not see much if the sun was not out.  Although it was cloudy, we decided to give it a shot (except Chelsea, who was still had a rumbly tummy).  It ended up being a lot of fun.  There were about 30 people on the tour.  Our initial guide was an enthusiastic Canadian girl who introduced us to a bunch of insects, including a bunch of 4 and 5 inch long cockroaches that she let crawl all over her.  She couldn't understand why we were all so grossed out, saying that these cockroaches were cleaner and more sanitary than humans, and popped one in her mouth to prove the point.  Lots of shrieks and groans for that stunt.  She also described in detail how the female praying mantis would bite off her sex partner's head in the middle of copulation, which had the effect of prolonging the mating experience for her.  She would then eat the rest of her partner, which gave her all the proteins she needed to give birth.  She remarked that the only species where the males were stronger was where they either cared for the offspring or defended the family.  I wondered if modern human society fit in either category.  We were then divided into two groups, where a Canadian guy (what's with all the Canadians, wondered Kirsten) enthusiastically took us through 4 different butterfly habitats and described each specie.  We got lots of neat pictures.  It was a nice note on which to leave Monteverde.

On the drive to Playa Grande, our beach spot north of Tamarindo, I made the mistake of listening to the GPS instead of following the map.  We ended up taking a 30 km detour down a bumpy dirt road.  It's like sailing, I kept telling myself.  As long as we get to our destination by dark, it's ok.  As we rapidly dropped in elevation, the temperature rose steadily, from the high 60s to the low 90s. We rolled into Playa Grade at about 330 pm, quickly changed into swim suits, and went to the beach.  Playa Grande is a beautiful crescent beach about 3 miles long, with an excellent surf break within yards of the beach.  The entire beach is a protected reserve for loggerhead turtles, the beach is closed at dark, and no lights are allowed to to be visible from the ocean.  (We're scheduled to go on the turtle tour on Jan. 1.) Anyway, we sat on the beach and marveled that we were only 50 miles as the crow flies from Monteverde, but it seemed we were in another country.  Here's a picture of our pasty white gringo bodies on the beach that first day.

We applauded when the sun set, then ate dinner at the hotel's restaurant, where we were delighted to see that we had left the inflation of Monteverde behind too.

We had rented three apartments owned by Las Tortugas hotel that were a short walk from the beach.  Josh and Chelsea have their own place; the three younger kids are in another apartment, each with their own beds; and Jennifer and I have a larger apartment with a small kitchen and dining room large enough to hold a table that seats 7.  It's working out great.  I made a grocery run at the local supermarket, and spent as much for a week of groceries as we usually spend for one dinner.  We'll be at the beach for 6 nights, and will make it up as we go along.  After not needing A/C in Arenal or Monteverde, here it is running constantly.

Sunday, December 30

Near as we can tell, there are no Mormons in the area, and we didn't feel like venturing into another church.  Instead, we all went to the beach and did a lot of nothing.  Jennifer and the kids built a huge sand sculpture of a loggerhead turtle, and decorated it with shells.  People were coming by and taking pictures of it.

Garrett got a nice sunburn on his back.  Josh discover the hammocks next to the hotel pool and has been reading the Hunger Games.  I borrowed some boogie boards from the hotel and we played in the surf, which has consistent 3-5 foot break in water that is waist or chest deep, but little turbulence, and a fine sandy bottom.  The kids vowed that they wanted to learn to surf.

Spencer got it in his head that we needed to see the Redskins play Dallas in the final regular season game, with the winner going to the playoffs as the NFC East Champion, and the loser going home.  There have been no TVs in any of the places we've stayed, so that might be a problem.  I called the Westin Resort in Playa Conchal, and was told no problem, the game is on, come over.  We loaded up and drove over, only to find that it was an exclusive members only resort that refused to admit outsiders.  The manager was rather rude, and shrugged off the fact that we had been told on the phone that we could watch the game at the sports bar there.  Fine, we'll take our business elsewhere, and I'll trash Westin in my blog.  So we drove over to Tamarindo and found a place that was showing the game and had a great time eating the dinner, watching the game, and cheering the final Romo interception. We left a 30% tip and went home happy.

Monday, December 31

I did another shopping run at the local Super Compro -- we are going through more milk and Diet Coke than I expected -- and we spent another day at the beach.  I talked the owner of the hotel into renting two longboards for $50 for the week, and we proceeded to make fools of ourselves trying to learn to surf.  I found that sitting on a long board is incredibly difficult, and paddling it is like moving the Exxon Valdez.  I succeeded in three things: falling off the board 24 times; getting 37 dirty looks from the real surfers; and re-learning the lesson I learned 20 years ago when I tried snowboarding for the first and last time:  this old dog is not learning any new tricks.

Chelsea did better, however, managing to stand up several times.  Kirsten was a bit more shaky, and Spencer spent 15 minutes getting his butt kicked by the waves before storming ashore, throwing down the board and announcing that he was never going to try that again.  Josh wisely stayed in his hammock and read.  We oozed between the beach, the pool, the hammocks, and the rooms for napping.  The entire beach applauded as the sun set on 2012.  After dark, I made RUPs (rolled-up pancakes -- a Dutch treat consisting of thin crepes, lots of butter and powdered sugar), and we played family games, intending to stay up till midnight, but we all ran out of gas and went to bed.   This is exactly what a beach week should be.