International Family Medicine

Haiti and its beginnings

2011-09-23T21:34:00.003-05:00

Columbus landing on the island of Ayiti

Many Haitians don't understand why we celebrate Columbus Day in the USA, as they look upon him as a foreign conqueror. He wasn't the first European to "discover" the Americas, that was the Norse explorer Leif Ericson. Columbus didn't even know where he was, as he thought he had landed in Asia, thus the term Indian was used to describe native populations. One of the first places he landed was Ayiti, as the local Taíno population called it, but he immediately renamed it La Isla Española (later Anglicized as Hispaniola.)

Columbus colonized the island and eventually ruled the island for a short time in the name of Spain. With Europeans and their old world diseases, the Taínos were almost completely wiped out, most likely because of lack of immunity. The ease at which cotton, sugar and coffee grew on the island prompted the transport of slaves from West Africa to the island. Plantations and forced labor became the norm. During this time the native Taíno population became extinct.

The island was fought over by the French, Spain, Britain and even European Pirates (on the isle of Tortuga). Eventually half of the island went to Spain (Dominican Republic) and the other went to France (modern day Haiti). The colony was one of France's most productive, surpassing all of their other colonial holdings. However slaves were enduring harsh plantation conditions and the indignity of forced labor. Thousands of slaves poured in every year and they soon became the overwhelming majority over and above the colonists.

Shortly after the French Revolution, the first revolts began on the island in 1791 and quickly spread across the island. Napoleon sent forces to try to keep the island under control of France but the revolts continued for the better part of a decade. During this time the slaves faced terrible torture at the hands of the French. A former slave wrote the following passage.

"Have they not hung up men with heads downward, drowned them in sacks, crucified them on planks, buried them alive, crushed them in mortars? Have they not forced them to eat excretement? And, having flayed them with the lash, have they not cast them alive to be devoured by worms, or onto anthills, or lashed them to stakes in the swamp to be devoured by mosquitoes? Have they not thrown them into boiling cauldrons of cane syrup? Have they not put men and women inside barrels studded with spikes and rolled them down mountainsides into the abyss? Have they not consigned these miserable blacks to man-eating dogs until the latter, sated by human flesh, left the mangled victims to be finished off with bayonet and poniard?"

In 1803 Britain went to war with Napoleon as well. France was no longer able to contain the slaves and they declared independence January 1st, 1804. They named the new country Haiti in homage to the native Taíno people. France had exhausted its coffers fighting the Haitians and now facing the British they were in desperate need of cash. In March of 1804 France sold the Louisiana territory to the Americans. In part we have the Haitians to thank for our land acquisition as they had helped to bankrupt Napoleon.

Nég Mawon blowing a conch with machete in hand.
The National Palace is destroyed in the background

The unkown slave also known as "Nég Mawon" came to symbolize the Haitian indefatigueable spirit as they had successfuly thrown off their shackles, becoming the first black republic. This would be the first of many challenges that the Haitians would face. They were surrounded on all sides by other colonial slave islands not to mention the United States still had slavery. As a result all parties were nervous that similar slave revolts would break out in their respective colonies. Strict trade embargoes were imposed so as to keep the slave revolution from spreading. France also forced Haiti to pay 150 million francs in reparations, not only for the land lost but also the value of the slaves themselves. Haiti did not completely pay this debt off until 1950's.

The combination of trade issues and crushing debt to France made for unstable government. Even the United states occupied Haiti from 1915-1931, and many thousands of Haitians were killed during this time. Coups, invasions, epidemics and dictatorships plagued Haiti until 1990 when Jean Bertrand Aristide was democratically elected. His populist focused politics frightened the ruling elite and another military coup overthrew Aristide less than a year later. The transitional military government held onto power with an iron fist until the US governement attempted to restore democracy by forcing the military out of power. Aristide was able to return briefly and when his term ended in 1996 Rene Préval was elected president, Haiti saw its first transition between two democratically elected presidents since its inception in 1804.

I feel that it is important to understand where Haiti is today because of its troubled past. Much of which was no fault of the Haitian people. This fragile state that the Haitian government and cities in also gives insight to why the earthquake was so damaging. "Natural Disasters" happen many places and have varied effects on the populations and the places that they strike. Paul Farmer in his latest book, Haiti After the Earthquake, asserts that this was more of a "social disaster." Haiti was the perfect place for a natural disaster to wreak havoc. The kindling had been building up for many years, the earthquake was just the match that made the country up in flames. Poor building codes, failing health and civil infrastructure prevented the Haitian government from mounting any sizable response. Add to that the fact that 75% of the government workers were killed on January 12, 2010, 90% of the cabinet buildings were reduced to rubble.

But the Haitians have seen adversity before. Think of the spirit of the fighting Nég Mawon. "Ayiti p`ap peri." Haiti will never be finished. And the Haitians have proven that. They will not give up, they will continue to fight to make their country better. I have seen it in their eyes and witnessed the monumental efforts that are going on here. It is my hope that the non-governmental organizations (NGO) and the money pledged right after the quake will strengthen the public sector of Haiti and contribute to its sovereignty. Of the $8.75 billion pledged after the quake only 15% of the money has been disbursed and of that money only 0.1% has went to strengthen the Haitian government. In the end it will be the Haitian government holding the ball and all of the blame as the NGO's continue to pull out. Of the 790 NGO's that entered Haiti, just as many have now left. Heart to Heart is one of the few remaining NGO's who have commited to the long term.

Heart to Heart has clinics in Leogane and in the heart of Port au Prince in Bel Aire. They travel to remote regions like Fondwa, Bell Anse, Cascade Pichon and Forest de Pins. In addition to medical clinics Heart to Heart has expanded their focus to community develpment and education. They are building clinics, schools, and cholera treatment centers. Adult literacy has been a focus so that academics will be encouraged in children. When the Cholera epidemic hit Haiti last year, Heart to Heart successfully mobilized supplies and educators to an area where no other NGO or the government could reach. They educated over 15,000 people and cholera today is under fairly good control in the region.

As I make plans to leave Haiti again to go back to work in Iowa. I know that the resilient Haitians can pull through. Focusing on "building back better" through public/private partnerships is going to be key to give Haiti the helping hand that it will need to be self reliant in the future. Until then, there is a lot of work to be done.

See you in Haiti!

Return to Haiti

2011-09-02T21:48:00.016-05:00

The valleys near Fondwa

Returning to Haiti has been a sobering experience. The last time I was here was one week after the quake. Most of the medical care at that time was related to injuries that people had suffered during the quake. I saw broken bones, infected wounds and various complications related to physical trauma. The landscape looked like a war zone, dazed people wandering about, rubble everywhere, people still trapped under buildings, human tragedy was rampant.

Now, a year and a half later, Haiti is looking better. Much of the rubble and downed buildings have been cleared away, new foundations are being laid. Overall it does looks like things are improving--slowly. Slower than I would have hoped. The recovery and rebuilding is still very spotty. Port au Prince, the capital city, is still getting most of the attention from international NGO's. The rural areas and people in the mountains are still largely without medical care.

Talia preparing medications for patients.

I am here in Haiti again with the wonderful organization Heart to Heart International. I have been working with Talia from Philadelphia and Judy from Kansas City. Most of my time has been spent with the "Mobile Clinic" based out of Léogâne. Everyday we pack up supplies and medicines and drive out to some of the remote sites with poor access to care. Heart to Heart has partnered with local churches and organizations and the mobile clinic visits a different site everyday of the week. They have a simple charting system that allows for continuity of patient care from week to week. This is very important now since most of the medical care delivered is now for chronic ailments such as hypertension, GERD, asthma, etc.

Today we visited the mountain village of Fondwa. Heart to Heart has placed a "Clinic in a Can" on the side of a mountain. The "Can" is actually a specialized shipping container that has 2 exam rooms, a pharmacy and is outfitted like most clinic rooms you would find in America. It is able to be shipped anywhere in the world and driven by truck to any location with a road. The road itself was very precarious and I'm not sure how they even got this thing up there, but leave it to the Hatian drivers to do the impossible.

I examined two obstetric patients who were 8 and 5 months along who hadn't seen a doctor their entire pregnancy. They weren't exactly sure where they were going to go to deliver. One woman told me she planned to get in a Tap-tap (taxi) and drive to any hospital that would take her in Leogâne when she went into labor. I was white knuckled the entire hour long ride up and down the mountain, impossibly narrow roads, ridiculously steep grade. I can't imagine doing the same trip in the back of a taxi while in labor.

I can say one thing about the Hatians, they are resilient. For the amount of damage that was done to their country and for them to continue to claw back to where they currently are takes an incredible amount of courage and moxy.

We visited an orphanage in Léogâne as well. I have been to many orphanages around the world and this was one of the most heart-rending experiences that I have had in a while. The orphanage is run by three Haitian women who have taken it upon themselves to take care of 27 orphaned children. They have little financial support and they are constantly scrambling to make ends meet. Most of the children lost their parents in the quake, some have severe developmental problems and their parents were unable or unwilling to take care of them. The first room I happened upon broke my heart. There were 8 toddlers lying on a bare tile floor without any diapers on. Later we were told that they had run out of diapers so that was all that they could do for them. One child was rocking himself in the corner and another was slumped in a plastic chair. We brought candy and made balloon animals and were able to lighten the mood a little. The kids were having a lot of fun by the time we left. Yet the other volunteers and I left the place with a heavy heart. It is one of those situations where you feel powerless to help someone in need. When that someone is is a small, helpless child the impact is that much more powerful. The volunteers and I are going to be discussing with Heart to Heart a way to help this particular orphanage get more stabilized support. When we get a plan hammered out I will let those interested know how best they can help.

What I took away from this is that there are still many people suffering needlessly in Haiti. For all of our own day to day troubles and annoyances that plague our lives and consume our thoughts, they are very small when confronted with the harsh reality of a child living in an orphanage or a pregnant woman stranded on a mountain top. How many other people are suffering in the shadows unseen? I know that it is impossible to help every person in Haiti, yet I can't help but think that we are not doing enough.

Keep Haiti in your thoughts. They are desperately trying to fix the broken bones of their country, we are needed to help make sure that the cast is well applied.

Back to Zimbabwe

2010-09-15T18:45:00.000-05:00

It has been great to be back in Zimbabwe. I hit the ground running upon my return to Karanda Hospital two hours north of the capital city, Harare. There are so many needy people here that, at times, it is overwhelming and difficult to know where to start.

For the first few weeks I worked in the female and maternity wards. I treated many people with various types of illnesses and infections. There are so many people here with tuberculosis and HIV. They really are the scourge of Africa. Many people here work in the fields as subsistence farmers. As such, many don't have the resources or education to be able to make it to the hospital early in the stage of their disease. We see many advanced cancers and infections as a result. Often we are only able to provide palliative measures to the patients.

Most of the normal deliveries here are handled by midwives. Occasionally there are problems with the labor process and the midwives call the doctors. I was fortunate to help many new mothers deliver during my time in Zimbabwe. Some required Cesarean section, while others just needed more encouragement. I was pleased to provide both. One of the mothers came in with pre-term labor. She was able to get the appropriate medicines prior to delivery and she had a little girl that weighed in at 1 and 3/4 pounds. We were able to teach the mother how to feed and care for her preemie and by the time I had left, the baby was doing well and going strong at 2 and a half pounds.

I also worked in the Male and Pediatric Wards near the end of my time. In the Male ward there is a lot of traumatic injuries. Many of the patients are victims of road traffic accidents (usually oxen pulled carts), others are injured in their workplace and occasionally there is a land mine victim. As a result, we do a lot of orthopedic surgery, casting and laceration repairs.

In terms of pediatrics, Karanda is one of the few places that can treat children with hydrocephalus. This is a condition where the normal cerebrospinal fluid doesn't properly drain and the head can become very large. In the United States we catch the disease early but in many countries there aren't enough doctors that can perform the procedure. At Karanda we often treat hydrocephalus patients not only from Zimbabwe, but from surrounding countries like Mozambique, Zambia and Botswana.

Providing medical care in resource limited environments can be a definite challenge. It is absolutely maddening when you lose a patient that you could have saved if you only had the right medication or treatment. The lack of availability of certain radiology or lab tests can make diagnosing a patient very challenging. However, mixed in with the bad there is often a silver lining. There are things that keep you coming back, like the smile of a recovering child or the laugh of an elderly man as you clumsily speak the local language. At the end of the day, it feels good to give some hope to someone who thought that no one would be able or willing to help.

The Baltics

2010-06-27T11:49:00.000-05:00

The Baltic nations are generally considered to be Estonia, Latvia and Lithuania. Finland is sometimes grouped in as well because the Finnish language shares its origin with Estonia. Latvia and Lithuania each have their own languages but are linguistic cousins. The Baltic nations have been occupied by other nations many times during their somewhat tumultuous history. The Swedish, the Polish, and Tsarist Russia all occupied the Baltic nations at some point or another. After World War I, the three Baltic nations declared themselves independent. They fought the Germans and the Bolshevik Russians to finally attain their freedom in 1920. In 1939 Nazi Germany and Soviet Russia signed the Molotov-Ribbentrop pact which basically divided Poland and the Baltics between the two larger nations. Shortly thereafter, the three nations were invaded and forcibly incorporated into the USSR. The pact was later dissolved when the Nazis invaded Russia. To the left is an example of "Flamboyant Gothic" architecture at St. Anne's Church in Vilnius and a statue of a Lithuanian poet Adomas Bernardas Mickevičius.

The Baltics suffered under Soviet rule. Over 200,000 people were deported and close to 75,000 were sent to the Gulag to penal work camps. However, the three nations never gave up their struggle for sovereignty. In 1989 a human chain was formed that started in Vilnius, Lithuania at the Gediminas Tower I'm standing on to the right. The chain extended across all 3 nations all the way to the Baltic Sea. In 1991 the Baltic nations were the first to secede from the Soviet Union. This stand for independence by the Baltic nations contributed significantly to the destabilization and eventual fall of the USSR.

I started my exploration of the Baltics in Lithuania. I quickly discovered that meat and potatoes are the mainstay of the diet. They get very creative with the manner in which those two items are cooked and paired. One of the traditional foods there is called a zeppelin, which is basically potato starch stretched over a mound of ground beef. Cover the whole thing in a sour cream based gravy and you have yourself a zeppelin. Potato pancakes (bulvinial blynai) are also very nice, often served with sour cream on the side and maybe some black currants.

From Lithuania I headed north to Latvia where I met up with my friend Tejas, who I hadn't seen since the last time we met up in India. He was traveling with his friend Pablo, who is going to a wedding in Spain. Here you see us imbibing a nonalcoholic drink called kvass. Kvass has a slightly sweet bread like taste and is made by fermenting wheat, rye or barley. It is popular in the Baltics as well as in Russia.

Riga is the capital of Latvia and with almost a million people it has a very metropolitan feel mixed with the old world charm. In many ways it reminded me of Russia. In fact, 30% of people living in Latvia are of Russian descent and don't even speak Latvian, a bit of a sore subject for the native Latvians. In 2004 Latvia joined the European Union and NATO. You get the feeling that the people are slowing separating themselves from their Russian past and are embracing their European future. The people all dress very fashionably in the latest European styles. The cafes all have tables next to the streets with people drinking espresso. I found most Latvians speak very good English, but a Latvian greeting of "Sveiki" will definitely endear you to the locals.

After Riga we hit the road and traveled further north to Tallinn, Estonia. Although each of the Baltic nations have joined the EU, they still haven't adopted the Euro as their currency. So it is a bit of a hassle when you are traveling from one country to the next in such a short period of time. Here you see me pictured with 500 Estonian Krooni which is about $40. The prices in the Baltics were relatively cheap compared to other parts of Europe but some items were definitely more pricey than back home. While we were in Estonia the US Marine Corps were there as well training with the Estonian Troops in forested combat. Most were from L.A. but some were from Tulsa, OK. They happened to have their one night of leave in two weeks the night that we were in Tallinn. So it was kind of strange to have about 500 young American soldiers running amok in the city while we were there.

The Baltics are and up and coming part of Europe with plenty of history and architecture to satisfy the mind and just enough Western comfort to allow you to relax and enjoy yourself. If you want something off the beaten path and away from the tourist traps in central Europe, this may be a place for you to explore.

Atta!

Castles, Lochs, and the Highlands

2010-06-17T13:43:00.001-05:00

After leaving Mildenhall, the group headed up to Edinburgh, Scotland. It is the capital of Scotland and a nice city. Overlooking the city, high upon the hill is the castle. It has been around since the 12th century. It sort of winds itself up the mountain and is the centerpiece for the city. . The castle comes equipped with cannons to fend off would be invaders. It has been besieged many times throughout the centuries, both successfully and unsuccessfully. If you peer off of the edge of the battlements you get amazing views of the city. You can definitely tell why the builders chose this site to fortify.

Also present is the Royal Scottish Regiment who defend the castle. Despite their traditional uniform and kilt, these guys have actual rifles and are posted here on active duty. Every hour in front of the castle they have a changing of the guard ceremony. They do patrols around the castle and if properly approached you may have the chance to do a Royal Scottish Fist-bump (with our without squirrel).

While we were in Edinburgh the United States vs. England World Cup Soccer game was played. Probably like most Americans, I had not watched a soccer game in a long time. The Europeans love soccer, or football, and they pack all of the sports bars watching every game intently. One thing I was suprised about was how much the Scots aren't fans of the English. The pub that I was in was packed and all of them were going for the USA. People were running around with US flags chanting USA USA. When people there found out that we were from the States they got real excited and were giving us high fives every time that team USA did something good. One particularly interesting Scot had a t-shirt on that said "ABE, anyone but England." He was real excited and hooting and hollering and became our friend. By the end of the game USA, the underdogs, held England to a tie. Actually a pretty big upset for team USA. Our Scottish friend gave me a pin that had the USA and Scottish flags on it. I'm still not a huge fan of soccer, but in that environment it was definitely pretty fun to be a part of the World Cup frenzy that is going on in the world right now.

The next day we headed north on a tour of Scotland. We started in the lowlands and worked our way to the highlands. Nearby Inverness is the famous Loch Ness, the site of the elusive monster. The loch is about 800 feet deep. The water has is very murky, almost a black color from the run off of peat in the nearby hills. This, of course, contributes to the mystery associated with the legendary beast lurking below the surface. The loch is situated in a long glacially carved valley with high hills on both sides.
There is an man made island called a crannog. Crannogs were built by people long ago as a defense strategy. If threatened, people would retreat to the island to hide or have a better chance at fending off their foes. There are many crannogs all over Scotland and they are discovering that islands previously thought to be natural are actually crannogs. They are often built by submerging logs in a ring and then filling in the middle with stones. Back when they were in use there was usually a gangway connecting them to the shore for quick utilization.

We continued our tour of the gorgeous highlands. The mountains are very geologically old compared to younger ranges like the Rockies or Alps. Because of their age they are rounded, less craggy and covered in a beautiful green. The clouds encircle the peaks in a fantastical manner and it is really a wonder to behold. We stopped at a particuarly stunning group of peaks called The Three Sisters. I'm sure it was places like this that inspired J.R.R. Tolkien to write his epic fantasy novels. It was truly a magical place and absolutely worth a visit.

The last place we went by was Stirling, set at the border between the lowlands and the highlands. This was the site of important battles during the Scottish Independence. William Wallace and Robert the Bruce both fought here against the English. On the hill is a large monument dedicated to William Wallace.

It was a great visit and gave me a taste of the north country. Scotland is definitely a land with an interesting history and still retains amazing beauty even today. I look forward to coming back sometime and spending more time exploring the hills and history of this great land.

Alba gu bràth!!

Mildenhall, an unlikely place for new and old friends to reconnect.

2010-06-16T10:34:00.000-05:00

After leaving London we went to Mildenhall, UK, a city close to Cambridge. There is a United States Air Force base here and one of my friends, Darby, lives here. Her husband, Bill, is stationed here as an air traffic controller. She was gracious enough to let me stay in her house and provide some tours of the local area.

I first met Darby through her brother, Chet, with whom I went to medical school at KU. Through Darby I have met many people. Two of which are also traveling through the UK. Anona is Darby's cousin from California and Sheila is an ex-coworker from St. Louis. Bill's brother also happened to be traveling through Mildenhall at the same time. As I mentioned in the title, Mildenhall is a somewhat unusual place for friends from all over the United States to coalesce, but it works out nonetheless.

There isn't too much to see in Mildenhall but we did enjoy a traditional English tea. I have to admit I wasn't too excited when I heard we were going for tea. Even after living in Zimbabwe for 5 months I haven't been converted to a tea drinker. But all of the girls were thrilled to go, so I went along for the ride. One thing that is difficult for us Americans to understand is the word tea. To us it is usually cold fluid made from baggies of brown leaves. To the English it is not merely a drink, but an event. Tea can mean a break from work, it can mean lunch, it can even mean dinner. The place that Darby brought us to in Mildenhall was a Victorian traditional tea house. Complete with ladies in serving outfits with little bonnets. "Tea" in this case happened to be a four course light lunch. The first round of which was our actual tea, chosen from a menu of about 30 varietals. All of the standard teas were on the menu such as Earl Gray, but also black teas, white teas and even Indian Chai. I opted for an iced fruit tea. The next course was a sandwich course. We had brie and grape sandwiches and amazing cheddar with sweet onion chutney sandwiches.

The third course was biscuits, or as the English call them, scones. You could choose between plain or fruit.scone. They also brought strawberry, blueberry, rasberry and black currant jams. They topped off the whole thing with a thick layer of powdered sugar. In the center of the dish was "clotted cream." Which on the menu sounded very unappetizing to me, but turned out to be a cross between whip cream and butter. It melted like butter but didn't have that salty taste that normally accompanies butter. It went marvelously with the scones and the black currant jam was packed with spice and other flavors, almost like a spice marmalade. The last course was finished off with a cake of our choosing. I went with the dutch chocolate, it was pretty chocolaty. We did pass all of the cakes around and, in my opinion, the carrot cake just barely edged out the English sponge and strawberry cake. So break down your cultural barriers and think of tea not simply as a drink, but as something to be savored, enjoyed. I was definitely surprised to push away from "tea" with a very full belly.

Darby then took us to the smallest pub in the UK called "The Nutshell." It is literally a room with a bar in it and barely enough room to turn around in. It has a unique character. By unique I mean strange. I'm not sure if the decor of dead animals on the wall (including a cat, a rat, a mouse, a fox, an antelope, a jackalope and what appeared to be a human foot), or the clientèle were stranger. One hyperverbal man, who wouldn't stop talking to me about Nepal, ended up telling me about all of his trips there. He eventually pulled out 8 x 10 glossy photographs from his various forays and proceeded to tell me about all of the people he knew there. Another man swore I was a famous bearded man in his magazine, and kept telling all of his friends and laughing. I did touch the 400 year old cat hanging from the ceiling, after which I was informed that it was bad luck to touch the cat. Apparently, the only way to get back the luck was to lick the hideous creature. I am glad to say that I am not a superstitious man and I declined the to taste the petrified feline. Needless to say, it was a very eccentric pub, however I am not sure that I would go out of my way to visit.

Overall it was nice to reconnect and see where Darby is living. Besides the strange bars, at least she has a nice place to go for a spot of tea. After Mildenhall we all packed up and headed to Scotland.

Cheers!

London

2010-06-13T20:00:00.001-05:00

We flew into London via Ryanair, which was an experience in itself. If you haven't heard of Ryanair, they are a low cost Irish airline that flies to most destinations in Europe. They often advertise flights for as low as 5 Euro. There are usually quite a bit of taxes and other things added on, but you can still usually end up with a ticket for less than 50 Euro. They are definitely no frills and they go a step beyond and are pretty restrictive. Baggage requirements are meticulously monitored for weight and size. If you go over on either, you will be charged.

We opted for the classic bus tour around the city. They have a hop-on/hop-off bus system that is really very nice. After you buy your ticket you can get on any of the buses for 24 hours. They issue you a set of headphones and you can listen to fun acts about the city in your native language. It was actually a very efficient way to see all of the major sites in a very short period of time.

Big Ben was of course a must see. Funny thing is that Big Ben is actually the name of the bell, not the tower. The bell isn't even in the clock tower itself. The Londond Eye, basically a huge ferris wheel, dominates the view from the Thames river. We also went to the Tower of London, a big castle where you can view the crown jewels. Very impressive hunks of metal and rock. Probably out of my price range though.

We finished off the day in the theatre district by watching The Lion King. Amazing show if you haven't seen it. Julie Taymor's puppets take your breath away with their odd movements and sheer genius in stagecraft all wrapped into one African musical extravaganza. If you liked the Disney movie, you will love this play.

Cheers!

The Land of Eire

2010-06-11T18:26:00.000-05:00

Ireland is amazing. The people are nice. The land is beautiful and the beer is Guinness. I mean seriously, if you don't drink Guinness when you come to Ireland then you are missing out. On the first day of the Dublin adventure I made the trip to the Guinness Brewery tour. They don't actually brew the beer here anymore but they have a big museum dedicated to the lore of the brew. The end of the tour you get a pint and a good view of the city. You also have to have the full Irish breakfast, but bring your appetite. The usual fare consists of the following: eggs, 2 rashers of bacon, sausage, black pudding (blood sausage), white pudding (minus the blood), potatoes, brown soda bread, half of a roasted tomato, mushrooms and tea. You really feel like wrestling a bear and/or gator if you are able to finish the breakfast.

I was able to meet up with Paul, an Irish friend of mine who I met in med school. He is a surgery resident here in Ireland working on research at the moment. Unlike the USA, when Irish medical students graduate they have a Bachelor's in Medicine. If they want an MD then they must undergo further training and usually write 2 or 3 academic papers before being allowed to continue on to higher degrees.

Besides being a doctor, he also makes a good tour guide and walked us around various places in Dublin.

We visited Trinity College where the Book of Kells is located. The Book of Kells (click for more info) is a collection of 4 gospels from the New Testament dating back to the 6th-9th centuries. They have portions of the manuscript on display. They also have an amazing library that reminds me of something out of Harry Potter. Two levels and a lot of very old books. Walking through the incredibly long hallway makes you appreciate the vast tomes of knowledge that have been collected. With the internets, something like this great library will never be built again, which is sad in a way.

After thoroughly exploring Dublin we headed to the Cliffs of Moher located on the Western Coast of Ireland. The sheer, green topped cliffs are constantly battered by the Atlantic Ocean. Absolutely a must see if you come to the area. They have spent quite a bit of money revamping the area for tourism. Most of the time you are safe from falling over the edge thanks to people corralling barricades.

We then headed south to Cork, the Texas of Ireland. They are known for their rebellious attitude.. They never quite do what the prevailing government would like them to. Their independent streak is also melded into their overwhelming pride. Someone from Cork would gladly tell you that there is no where better in the world. This is probably best demonstrated by the Republic of Cork shirts available in the gift shops.

Next up: London.

Sláinte!

Liberty

2010-06-04T21:55:00.000-05:00

The last few days in New York have been great. Nicci and Joe took me out for another NYC foray. We tried to get up early as today our destination was the Statue of Liberty. I have visited the city on several occasions but had never been onto Liberty Island to get a close look at Lady Liberty.

There is a ferry that leaves from Battery Park. Battery Park is the site where an old cannon battery is located. The battery still exists and you can still see some of the cannons pointing out into the water to fend of enemies of yore. It is usually a pretty busy place with street performers and endless hot dog and pretzel stands. When we were buying our tickets Joe got a discount on his ticket because of his Military ID, as he is in the Marine reserves. The lady also threw in free pedestal level access to go inside the statue.

The ferry over to Liberty Island is a short trip and you get some awe-inspiring views of the statue from the right side of the boat. We walked around the island and it was a good feeling. It felt as if we were doing something every American should do, something patriotic. When you enter the statue there is a small museum. They feature the old torch that they removed some years back. The glass was beginning to crack and so it was replaced with the new torch that is currently on the statue. There is also the history of the Bartholdi and his vision leading to the creation of the statue. We climbed up to the pedestal area just below the feet. There we got a great view of Manhattan and Ellis Island. Tours to the crown apparently required special reservations and more money so we didn't get to go all the way up.

The ferry then took us over to Ellis Island. It was pretty interesting to be visiting the building that so many immigrants passed through on their search for a better life. The entrance hall is very large and seeing the pictures of the crowded immigrants packed into the same hall was sobering. You are able to search their electronic database to find records of your family if they entered through Ellis Island. They do ask for donations if you visit their research center, but the same information is available online for free if you are interested. I couldn't help pondering attitudes towards immigration back then and contrasting them with those today. I think we still have people searching for the opportunity only available in America. The immigrants are coming from different places now, but they have the same dreams. Often they seem to be willing to work harder and have greater vision than some of the citizens here to fail to take advantage of all this amazing country has to offer.

After Ellis Island we hopped back on the ferry to Manhattan. Our next objective was Broadway! Nicci's mother was able to get discount tickets for us and we went to see South Pacific. It is playing at the Lincoln center, right next to Juliard. Overall it was a good musical. Rodgers and Hammerstein seem to know how to create theatre that remains somewhat timeless. The actors all had good voices, as expected in Brodway. If you haven't seen it, it is probably worth it as it might not be on Broadway forever.

Stay tuned for Dublin....

The City

2010-05-31T23:22:00.007-05:00

Today Nicci, her brother Joe and I tackled Manhattan. We left from their suburban home near Nanuet and, after a few minor traffic violations, we were on the George Washington bridge in about 30 minutes. We didn't have much of an objective. We just wandered about the city and did whatever came to mind at the moment.

That's Nicci and Joe on the left in Time Square. I got to practice using my camera's panoramic function and came out with some pretty cool pictures.

It was a fun day in that it was very relaxed and we weren't worried about being certain places at any prescribed times. We spotted Magnolia Bakery and had to go inside. Magnolia Bakery is famous for its cupcakes. They are moist, delicious and heaped with frosting. You may recognize it from various pop culture movies and television shows that mention it. I got the hummingbird cake with the sweet cream cheese icing. Nicci went for a vanilla cake with pink frosting and Joe opted for the devils food with caramel frosting. (I threw in a German chocolate just to justify getting a box)

We then headed to Central Park and strolled amongst the people enjoying their Memorial Day. We eventually settled down next to the pond and enjoyed our gourmet cupcakes.

We lallygagged in the park a little while longer before we had the urge to get some real food. Then operation Processed meat went into effect. We decided that we needed to get a hot dog. Of course if you are in NYC then you can't just get any hot dog. No only the best hot dog would do. Papaya Dog is often cited as one of the best, if not the best, in the city. Problem was, we were uptown and the Papaya Dog is downtown. So we decided to take a subway down to the Lower East Side in search of the greatest hot dog that Manhattan had to offer. Forget the fact that we passed hundreds of hot dog stands all day and that our subway rides to get to Papaya Dog cost more than the hot dogs themselves. No, we were on a higher mission to experience something great. It is probably one of the best classic hot dogs around. I still feel that Pink's in Los Angeles probably has it beat in the creativity department. I mean it is hard to compete with the bacon, cheese and chili burrito dog, but it is still a great dog and worth the extra effort if you are visiting. To top our hot dog excursion we had some NY style pizza at Iggy's. More pizzas should use fresh mozzarella. It is amazing.

We eventually made our way back to our car which was parked in the garage. We begrudgingly paid our exorbitant parking fee (don't forget about 18% tax) and headed back home.

When we got back, Nicci's grandmother was over and was preparing an Italian feast. I was already stuffed and thought I could not eat another bite from our NYC excursion. However, when I was presented with homemade meatballs and manicotti (pronounced by New Jersey Italians as "manigot") overflowing with ricotta and fresh mozzarella, I could do nothing but continue to stuff myself even further with even more amazing cuisine.

Needless to say this was a great day for food and I can't wait for what adventures are in store for tomorrow.

Delisi Home

2010-05-31T09:40:00.003-05:00

My trip to Newark was uneventful. I arrived and Nicci picked me up. Nicci is a nurse that I worked with in Zimbabwe. Living in the same house in Africa for 5 months you get to know them pretty well. She had invited me to come to New York and visit. So here I am.

Last night I stayed in her parents house in very nice accommodations. Nicci and her family are of Italian descent and they are very warm and welcoming. They are also very good cooks! I benefited from Nicci's cooking many times while in Africa. Spending time with her family I now know where she gets her kitchen expertise.

They made homemade pizza for dinner last night, one was pesto and the other was prosciutto and ham. Delicioso! This morning her mother made pancakes and Nicci made an egg soufflé type of dish with salami. Also very delicious.

We are going to head into New York City today and see some sights, so it should be a good day!

Ciao!

The Journey Begins!

2010-05-30T11:22:00.001-05:00

As the wichita chapter of my life closes new paths are yet undiscovered.
Today I begin my journey through Europe. I am choosing to go off the beaten path and explore the oft forgotten locales.
Today I fly to New York where I am meeting my friend Nicci. I met Nicci in Zimbabwe where she was working as a nurse during my time there.
I know that many adventures are yet to unfold. I am definitely looking forward to this trip before I start my life anew in Iowa.
Stay tuned...

Culture Shock

2009-09-03T03:07:00.003-05:00

Well I've been in Zimbabwe for about a month. I think it has taken a while to adjust to living here. When you first come to a new country you are hit with all of the new sights, sounds, and smells. Everything is new and your brain attempts to take it all in, like a giant sponge soaking in the essence of your new surroundings. It is an impossible task at first and at the end of the day you feel tired and discombobulated. People react in different ways to your behavior, you are completely thrown by some of their actions. When the world seems turned up on its head and you don't know down from up, you are experiencing culture shock.

Culture shock is basically the process that you go through as you are adjusting to your new environment. Depending on how significant the change is usually correlates to the amount of shock you feel. If its the first time you have been out of the country you may have a dramatic response. If you are used to a certain level of comfort or standard of living and you completely remove it, you may have a difficult time adjusting.

Here are some ways that you can mitigate the tumultuous ride down the culture shock train.

1. Be Open Minded
People in other places do things differently so expect the unexpected. You are going to experience different traditions, foods, and mannerisms so embrace them. If your response to these differences is resistance then you are likely to have a rough transition. Go out of your way to try new things. Remember Rick's prime directive: Don't eat at restaurants you have back home!

2. Extend the Olive Branch
Try and learn some of the language or the local customs. Learning the local greetings and being friendly goes a long way towards easing the discomfort they may be having with you. If you learn what is offensive to a culture you are less likely to inadvertently embarrass yourself or others.

3.Take a Step Back, Don't Retreat
When all else fails and you feel as if you are falling down the cultural well of despair grab onto something familiar. Call home, eat at McDonalds (try not to break the prime directive too often), open up that Snickers bar you were saving. It is natural to cling to the familiar and, at times, it can be therapeutic. When you are traveling and you meet someone from back home there is this inherent comfort that goes along with talking to them, even if the person is a complete stranger. But you can take this too far and begin withdrawing from the local culture. If you try to shield yourself in a little bubble of familiarity and stop interacting with the locals then you are losing the battle. After all, what is the point in traveling if you surround yourself only with people or things from back home?

So Jack and I have been doing well. We have slowly begun the adjustment process and I think we are both recovering nicely from the culture shock. We still have a lot to learn, but we definitely feel more firmly planted.

Toanana Mangwana

Rick

Mission Medicine

2009-08-16T16:11:00.004-05:00

Jack and I successfully survived our first week here at Karanda Hospital. We are well fed and we haven't been bitten by snakes or eaten by lions. We have been working too. The picture on the right is Dr. Dan Stephens removing an eye that was injured.

Just to give some general background, Karanda is located 3 hours north of Harare near the Mozambique border, basically in the middle of the bush. Click here to see a Google map of the hospital (I live in the big square in the middle)

The hospital is divided into 4 main wards: pediatrics, maternity, male and female. There is also an outpatient department (OPD) and several operating rooms (operating theatre as the Brits call it).

The general daily routine is as follows:

7:00 Chapel
8:00 Ward Rounds
10:00 Tea time
10:30 OPD or Theatre
1:00 Lunch
2:00 OPD or Theatre
We finish when the work is done.

Jack and I alternate who is in theatre and who is in OPD. Whoever is on evening call is responsible for doing emergent C-sections and any other traumas that roll in during the night.

Overall, the medicine is very different than I am used to. Of course there are different tropical diseases like malaria or parasitic infections, but also, people tend to present with more advanced illness as well. The high prevalence of HIV and tuberculosis always clouds the picture when you are trying to figure out what is going on with a patient.

Diagnostic tests that I order with little thought back home are very expensive here and must be reserved for severe cases and only ordered when you absolutely need them. Other tests like CT scans or MRI are unavailable. Medicines which I know and use frequently in the US may have a different name here or may not be available at all.

So between the different diseases, diagnostics and medicines I feel like I am back in med school. Which basically means that I have a lot to learn yet about bush medicine. But, I guess, that is the point of doing a fellowship in Africa.

I think that Jack and I are settling in well. We have most of the basics down and hopefully we will continue to gain steam over the next few weeks. Our goal is to contribute to the workings of this busy mission hospital while gaining as much practical experience as possible. I think we are well on our way and we are lucky to be working at a place like Karanda.

Chisarai
(stay well)

To Karanda or Bust!

2009-08-08T15:51:00.005-05:00

We left Harare this morning to head to Karanda Hospital. Before we left, Jack and I had to pack up the food that we bought for the upcoming month. Between the 9 loaves of bread, 14 juice boxes, 8 UHT milk boxes (good without refrigeration) and countless ramen noodle packages, I didn't think that we would be able to fit everything in. We also had two coolers with our meat that we had frozen the night before. The drive to Karanda is 3 hours long and so you have to pre-freeze anything that might spoil during that time (no place to buy bags of ice).

I lugged the food to Jack and he masterfully packed everything and, to my amazement, it actually fit. We even had room for the baby kitten one of the other workers was nursing back to health. Overall, we were very proud of ourselves. That was until two more adults and a child showed up to ride along. The driver had neglected to mention that until after we took up all available space with our food...

Well Kirsten, the industrious physician assistant, showed us how Africans pack and she was able to squeeze all of our food and the three extra people artfully into the van. Some of our food had to go into the trailer hauling 50 bottles of bleach and some luggage had to be tied to the top of trailer, but in the end it worked out. We were off to Karanda (2 hours late but hey this is African time...)

The drive out was very pretty. Civilization melts rapidly away and then you are struck with a landscape that is truly breathtaking. Harare is situated on the high veldt (high plateau) sitting at around 5,000 feet. Karanda is in the low veldt and on into the valley. Driving through the mountains and then dropping suddenly into the African bush can be a startling view. The territory is rough and wild. Trees are tall and leaves are out of reach. Thorns are prevalent and very large. The sky is a piercing blue that contrasts with the dry African plains.

The ride to Karanda was uneventful. The last 7 kilometers of the trip was on a dirt road. Just before we get to the hospital we were confronted by a small river. As we pulled toward the bank I started scanning for the bridge, but to my amazement we just drove through the middle of the river instead and continued down the road. I felt like I was playing Oregon Trail and we successfully forded the river with our stagecoach.

When we arrived at Karanda we were surprised to find an oasis of civilization amongst the deep bush of Zimbabwe. A small village of buildings dot the area which include the hospital buildings, nursing school, and missionary housing.

Our guest house is far beyond anything that we were expecting. The accomodations that we were provided are very spacious and cozy. We have a full kitchen and living room. We have our own bedroom, each with their own bathroom and shower. We were told that, by the end of the day, the water tank often runs out so just be aware of that possibility and keep water in the fridge. You can see Jack is happy to be filtering water. The power goes out quite frequently as well, so keeping a flashlight handy is a good thing.

After getting our food and clothes unpacked we have settled quite easily into our new homes for the next 5 months.

I invited Jack to be an author of this blog as well, so hopefully you may see some posts from him. I'm not quite sure if he is the blogging type but I guess we will find out.

Fambai Zsackanacka!

The long road to Zimbabwe

2009-08-06T15:43:00.004-05:00

The time had finally arrived when I was to set off to Zimbabwe. I had the normal pre-travel butterflies darting around my stomach. Of course, I waited to pack until the night before my trip. I had stayed up too late and discovered several items that I had yet to purchase. The most notable being a stethoscope. Thought that might come in handy at some point during the trip...

I met Jack at the airport and we had a wonderful send off from our family and friends. We left Wichita and landed in Denver. We had a 4 hour layover there and I was able to meet my friends in the airport as well. So all in all it was great to have such an outpouring before going overseas. I think it reminded me that I am truly fortunate to have such amazing people around me.

From Denver, Jack and I flew Lufthansa so our next stop was Germany. We had a 9 hour layover in Frankfurt so Jack and I left the airport. We toured around the city and sampled the local bratwurst. Also I ate an amazing dish called the jaegerschnitzel. In general, a schnitzel is a thin, lightly breaded, piece of meat. The jaegerschnitzel that I ate was a delectable pork fritter with a healthy drenching of brown sauce. Copious amounts of mushrooms were heaped on to finish this hearty dish (thanks for the recommendation dad).

We lounged in a park off of Romerberg square and we both fell asleep in the grass. We awoke to find ourselves amongst some of the other park dwellers of Frankfurt. I think we fit in pretty well because we hadn't had a shower at this point in the trip.

We also took advantage of the German health system and saw a doctor at the airport clinic. We went there to get the cholera vaccine which is currently unavailable in the United States. It was very quick and efficient visit and only cost 10 Euros.

The next leg of our flight was roughly ten hours long. We flew into Johannesburg, South Africa. This was a long and uncomfortable flight yet we managed to get about 3-4 hours of sleep in.

We had about a 2 hour layover in Jo-burg and this was barely enough time to get through customs, get our boarding pass and then make it to the gate. The flight to Zimbabwe was only a few hours and was relatively uneventful. South African Airlines flew the last leg and I remembered what American flights used to be like. They served us a free meal and refreshments. You don't get that on most 5 hour US flights.

At last we touched down on Zimbabwean soil in the capital city, Harare (pronounced Hah-rah-ray). We had no trouble going through customs. It was very nice to see a "Via Christi" sign when we got through customs. A missionary named Chris was holding the sign and he was there to pick us up. He is from California and has been here since 1973. His wife, Joyce, was born in Zimbabwe to a missionary family. They were very nice and took us to dinner when we got here.

When we finally arrived at our room at the T.E.A.M. headquarters, we were exhausted. We had left Wichita on a Monday and this was Wednesday night and our first good chance at rest. Overall a long road. Thankfully we had a smooth ride with very little bumps. Here's to the next 5 months being just as smooth!

Toanana

Community Centers around Chiang Mai

2009-05-28T22:47:00.010-05:00

During my two weeks of Family Medicine I have visited various community health centers around Chiang Mai. Each of the centers that I visitited had different roles and functions in the community. Many of them are owned or administered by the government.

One of the places I went was th Rajanagarinda Institute of Child Development. This is a multidisciplinary center for children with developmental and/or psychiatric disorders. They have several pediatricians, pediatric psychiatrists, and orthopedists on staff. The children come to the center to receive medical care, physical, occupational and speech therapy. They have both inpatient and outpatient services available. The mothers are encouraged to stay with the children while they are here so that they can learn to deliver better care for their children.

However the most fun, by far, was the toy library. Here the children can borrow toys and books for up to three months at a time. Each of the toys have labels describing what aspect of develpment that is improved when the children play with this toy. For example some toys assist with fine motor skills and others help improve cognitive functions.

I also visited a tuberculosis center in Chiang Mai. Here they coordinate care for patients with tuberculosis. Not only do they diagnose and treat the tuberculosis for individual patients, they also educate local practioners on how to recognize tuberculosis. The physician director of the center stated that they even have programs to track down patients if they don't show up to take their antibiotics. He said they will send a team to their house to make sure that they are ok and adminster their medicine.

One of my favorite tours was at the McKean center just outside of Chiang Mai. This place was started by an American doctor in the 1950's. He established the center to treat people with leprosy. At the time the lepers were shunned from society and had few areas to go. After establishing this center he created a place where they could get treatment they needed and live life with dignity.

Today the center has expanded to include a rehabilitation center for the elderly and people who have suffered disability from traumatic accidents. There continues to be a community of people who are recovering from leprosy. Many of the people are refugees from Burma and have advanced, debilitating disease.

Again, Thailand continues to impress me with their medical facilities and social outreach programs. There are many challenges yet to tackle in terms of refugees and poverty, but the Thai government seems to be making progress towards fighting sickness and stamping out disease.

The Karen and Lahu Hill Tribes

2009-05-28T10:19:00.007-05:00

Dr. Greer took me and the Larson crew out to some rural areas. We visited two small villages. The journey to the villages took us out of the hustle and bustle of Chiang Mai and into the lush countryside. Dr. Greer had never been to the villages before so we stopped for directions a few times. After a few U-turns we headed into the hills surrounding Chang Dao. Carved out of the surrounding jungle agricultural fields growing corn and Teak trees emerged. The roads became progressively smaller and less maintained. After several miles of twisting road we arrived at the first village. This village was populated by the Lahu hill tribe.

The hill tribes are diverse groups of peoples who have migrated to Thailand from different places in Asia. They generally live in the upland rural areas of Thailand. The hill tribes are broken down into six major groups: Karen, Lahu, Hmong, Lisu, Akha and Mien. Each of these groups are culturally different from each other and the rest of the Thai people. They have their own languages, traditional dances and customs.

Historically the hill tribes have been people that knew no borders. They would often utilize the resources in an area and then move on. However during the modern times international borders and property lines have forced the hill tribes to change. The tribes often practice subsistence farming for themselves and their families. Because of their nomadic nature, the citizenship status of the groups are constantly in question which puts them at odds with the modern governments. Many of the hill tribes took up opium production as a means of making money. The Thai government worked to eradicate such practices and end the drug trafficking on the Burmese border. The current king, Rama IX, instituted social programs to teach the hill tribes to cultivate other cash crops and be more self sustaining.

The Lahu village that we visited was an interesting mixture of the modern with the old. Housing ranged from small thatched roofed hovels to larger tin-roofed structures. Chickens roamed free and several hogs were loudly oinking (oot-oot in Thai) in anticipation of food. Juxtaposed to this were several sattelite dishes. This particular village was a place where tourists come on tours and do homestays with the villagers. This is generates cash for the villagers and they are now able to afford some of the modern niceties.

We also visited a Karen village. This is a video of one of the "Longnecks" of the Karen people. Those born on a full moon are deemed auspicious and place rings around their necks. As they get older more rings are added which gives the appearance of having very long necks. In actuality the clavicles and shoulders are pushed down rather than the neck actually stretching.

I did find it somewhat strange that both the Karen village and the Lahu village were both showing signs of modernization. The whole attraction for Westerners is the unique culture and remoteness of these tribes.

From

The Hawthorne effect again proves that observation changes the observed.

Thai Delicacies

2009-05-26T12:55:00.005-05:00

After trying the "Siamese Crapes" above I found what I thought to be toasted coconut to actually be toasted garlic. It was filled with a slightly spicy and sweet mixture. It wasn't quite what I was expecting, but it actually still tasted pretty good.

Here we have some Japanese style Ramen. The soup is soy based and comes with pork and a soft boiled egg. Definitely recommend trying the ramen if you are in the area.

This dainty dish I discovered walking by a street stand. What appear to be mini tacos are actually a sweet little treat. The "shell" is made out of an egg based crepe mixture and cooked until almost toasted. A layer of meringue is spread on top and then it is then folded into the signature shape and allowed to cook until crispy. Flavored coconut then finishes the dish. Bite size and delicious.

Differences in medical care.

2009-05-26T11:50:00.005-05:00

As I have mentioned before the medical care differences in Thailand seem to be fairly minimal. After working closely with the doctors here I can say that I would feel just fine receiving medical care here. All of the physicians constantly surprise me with their up to date medical knowledge. The picture above is me and the surgery residents during rounds.

In terms of what kinds of medical cases that I have been seeing it is generally the same as back home and many other places in the world. Common things are common. Hypertension, allergic rhinitis or even appendicitis. Things we see back home are the same things that we see here in Thailand. I have seen much less type 2 diabetes than in the US. But I think the diet here is a little less fattening. They eat much less cheese, dairy and red meat than we do. I had a papaya salad today that was great (shredded papaya, tomatoes and peanuts) and very low in fat.

One difference is of course the health care system. Here there is a two tier system. A public and a largely private system. For those that don't have enough money to purchase private insurance they are guaranteed a certain level of health care by the government. This care includes outpatient care, inpatient care, surgeries and even their prescription medications.

The private hospitals are a little more spruced up, have private rooms and more staff. Some of the hospitals are so nice they resemble 4 star hotels. Thailand is actually a site where medical tourism is occurring. People from the United States or other countries will fly in and have a medical procedure. While they are recovering they are treated to fine dining and unmatched service. All of this costs less than the entire procedure would cost back home. I was told that a laparoscopic gallbladder surgery only costs about $300, for perspective that is an ER visit for a runny nose in the states.

I am working in a university hospital that is engaged in training residents. So it doesn't have all of the niceties that the private hospitals would, but it still delivers excellent care.

This is a picture of the waiting room for the outpatient department (OPD).

There was an interesting case that demonstrated one of the differences in Thai medical ethics and our own. A patient came into the OPD for a follow up after a breast biopsy. Before the patient spoke with the doctor the patient's son came to speak with the doctor. He told us someone from the clinic had told him that it was invasive cancer.

He said that it was his wish that his mother did not know that she had cancer. He felt that she wouldn't be able to handle the stress of finding out about her diagnosis. He had told her that the biopsy results showed that she did not have cancer.

Now in the United States it is unlikely that this scenario would have developed like it unfolded in front of me. We generally release medical information only to the patient and usually anything serious is explained in person.

In Thailand and other Asian countries, often it is the children's duty to take care of their parents and grandparents. As many as three generations may live in the same house. The duty of coordinating medical care and making medical decisions also falls to the children in many cases. In this instance it was decided to withhold the information from the patient. Her son stated that he planned to pursue some traditional medical cures instead of surgery or radiation.

Orchids in Mae Sa Valley

2009-05-16T23:09:00.004-05:00

Me and the Larsons enjoying the orchids.

Ma Sae Valley

2009-05-16T22:53:00.004-05:00

So this weekend the Larsons and I went to the Ma Sae Valley. It is a 40 minute drive from Chiang Mai. The valley is nestled among green rolling mountains and the entire area is covered in dense jungle. The area has become more developed as of late and has many tourist attractions popping up.

We hired a driver and ascended to the tropical mountain getaway that is the Ma Sae Valley. We started at the elephant center. This is definitely different than the typical western elephant show as they let you get up close and personal with the elephants. They actually encourage you to feed the elephants (they charge you 20 baht for a bundle of sugarcane and some bananas).

The show is pretty unique as well. They parade the elephants around, pose and have them play soccer. They also demonstrate how the ancient Thai people used them for work. They have the elephants drag some large logs around and stack them up neatly. They also utilize the elephants in more artistic endeavors by having them create paintings. If you ever watched the show Road Rules you may remember this place from the episode where the elephants painted the pictures. The mahoot places the brush in their trunk and the elephants paint recognizable things like flowers and elephants. All paintings are for sale, of course, in the gift shop.

After the elephant show, we headed next to the snake show. Here brave snake handlers defy reason and all safe practices and come face to face with the deadly cobra. The show includes the milking of poison from the cobras to prove that they are poisonous. A large python and some other smaller snakes also make appearances during the show.

Perhaps one of the more memorable elements of the show is the ringmaster. Throughout the entire show the theme to Rocky was playing in the background. Not the “Eye of the Tiger,” but the other one when he is training and running around. While this is playing the ringmaster lowers the music and throws in some comments for supposed dramatic effect. Some examples include things like: “Deadly cobra poison,” and “If he bites you, you go to hospital,” and “doctor very far away.” Well the mixture of the auctioneer like voice, psuedo-threats of danger and Rocky music had me rolling in laughter throughout the entire show.

Lastly, we went to an orchid farm and lazily wandered among the beautiful flowers and butterflies. Orchids are the national flower of Thailand and so are very prevalent here. Lizzy wasn't a big fan of the snake show but seemed to enjoy herself more amongst the flowers. All in all it was a good day.

“You can kiss the snake, don't let the snake kiss you!”

Wats up in Lampang

2009-05-13T08:18:00.007-05:00

The Thai word for temple is "wat." The temples in Thailand are stunning and too numerous to count. One of these ancient decorative structures would be impressive enough but there are literally hundreds dotting the landscape. Often, if a significant religious event occurs near a location it will result in a temple being constructed. When in Lapang, Gamon told me of a story of a woman named Suchada who gave a watermelon to a divine monk. When it was opened it was found to be made of jade. The jade then turned into a buddha and it now resides at Wat Lampang Luang (pictured above). There is another temple on the site near where this lady lived. The point is, temples abound in Thailand. There are 78 within the walls of Old Chiang Mai alone.

Temples in Thailand usually consist of at least two structures. First is the chedi. The chedi are often constructed with tall golden spires or created using some other precious metal. They often enshrine items like a bones purported to be of the Buddha or some other such relics. They usually have a square base and people walk around them ceremoniously and place candles and incense. Sometimes they place pieces of gold leaf on certain holy items or leave lotus blossoms to pay their respect.

The other stucture usually found at the temples are the viharn pronounced (wee-han). These are buildings of worship and learning. Before the public school system was in place most people got their formal learning from monks giving lectures in these decorative halls. These are their cathedrals and are often more ornate than the chedi that they are associated with.

Gamon told me an interesting story that happened at one of the temples years after it was built. Around two hundred years ago Thailand was occupied by Burmese forces. A general of the Burmese army was residing at Wat blah blah. A Thai hero named Nan Tip Chang snuck into the temple through a small drain. He then hid behind a pillar of the viharn and waited for the general to pass. As the general was strolling by the chedi Nan Tip Chang shot the general. You can still see the bullet hole in the iron fence at the chedi. In the picture above you can see that people place gold leaf and flowers around the hole.

Dasvidanya

Insects are a great source of protein

2009-05-11T01:46:00.005-05:00

So the next day after the wedding Dr. Greer's former Family Medicine resident, Gamon, was gracious enough to show me around Lampang. We went to several temples around Lampang which I will tell you about later. After going to many temples during the day I asked Gamon if there were any markets to explore. He said that he knew of one in town that would be interesting.

The markets in Thailand are very exciting. They usually occur at designated times when they block off certain streets and the vendors move to hawk their wares to the passerbys. A previously vacant street explodes into the hustle and bustle of commerce. You can buy anything from small trinkets to large pieces of art. The sights and smells of exotic food dazzle the senses. Grilled meats and strange fruit are around every bend in the road. Everyone jockeys for position and the attention of the customer.

Well one such stand caught my eye. This stand featured our friends the arthopods all gussied up and ready to be consumed. That is right, fried bugs. Well this particular stand had 6 of our creepy crawly friends to choose from. There were bamboo worms, crickets, locusts, grasshoppers, some strange larvae and what looked to me like giant cockroaches. Gamon was quick to correct me and tell me that they weren't cockroaches but instead they lived in the water. Well they looked a heck of a lot like cockroaches to me and so we will just call them water cockroaches.

Gamon, seeing my apparent interest in the stand, quickly purchased some bamboo worms and implored me to try them. I was able to convince him to film me during my tasting of the bamboo worm and the above video is the proof thereof.

It actually tasted pretty good. Slightly salty and very crunchy, almost like corn chips. Gamon said that when he was a boy his parents were farmers and did not have very much money. They could not afford meat and as such they often relied on insects as a source of protein. Well today Gamon is a family doctor and can afford meat. However, he says that he still enjoys the crunchy taste of the bamboo worm. After trying them I can't blame him.

Bring on the bugs!

Happy Mothers Day!!

2009-05-10T01:15:00.003-05:00

Special post for Mom!

It is a salamander I think...

This was taken at Wat Doi Suthep

Wedding in Lampang

2009-05-09T23:43:00.009-05:00

One of Dr. Greer's former residents got married this weekend and they were gracious enough to allow us to accompany him to the wedding. It took place in a town called Lampang which is an hour and a half north of Chiang Mai by car. Lizzy got motion sickness in the car on the way to the wedding. She had drank some hot cocoa before we left and as such the chocolate fountain came a bit before we arrived at the wedding.

When we arrived at the wedding the monk was chanting in Pali, which is an ancient language that is only used for religious ceremonies (like Latin in Roman Catholicism). During the chant which lasts for 20-30 minutes the monk wishes the bride and groom good luck and reminds them not to break the 5 precepts which are as follows:

Precept 1: Panatipata veramani sikkhapadam samadiyami
To refrain from destroying living creatures. (Don't kill)

Precept 2: Adinnadana veramani sikkhapadam samadiyami
To refrain from taking that which is not given. (Don't steal)

Precept 3: Kamesu micchacara veramani sikkhapadam samadiyami
To refrain from sexual misconduct. (Don't commit adultery)

Precept 4: Musavada veramani sikkhapadam samadiyami
To refrain from speaking incorrectly. (Don't lie)

Precept 5: Suramerayamajja pamadatthana veramani sikkhapadam samadiyami
To refrain from intoxicating drinks and drugs which lead to carelessness. (Just say no)

After the chant was over the monk then tied a string around the wrists of the bride and groom signifying their bond. This is the "Pook Mue," or Sacred Cord. Then the bride and groom's parents then encircle string on the heads of the couple and then connect another string in between them completing the connecting tie that binds. After this there is a procession of family and friends that can each tie more string onto the wrists of the couple. All of the guests wish the newlyweds financial success and many children.

After that the food is brought out and the revelry begins. At the wedding I was at there were 10 courses. Each of them more delicious than the last. Pictured above is one of the first courses with pork dumplings, pickled pork, stir fried pork, cashews and the infamous century eggs topped with pickled ginger.

Century eggs were invented as a way to prevent eggs from spoiling in times of plenty. To prepare the eggs they are wrapped in an alkaline mixture of ash, clay, salt, lime and rice straw for several months. The process results in a yolk that turns green and has a creamy texture. The egg white becomes a translucent brownish black color. I was hesitant to try the delicacy at first, however they don't taste near as bad as they look. A definite must try if you are in the area.

The evening continued late into the night. Further courses included spicy cabbage and sesame covered anchovies. Fish belly soup was surprisingly tasty. The roast duck emerged with the head still attached.

Before the wedding was over the children became restless and we left the wedding. In the parking lot we discovered that someone had double parked behind us and after several announcements the culprit emerged and moved his car. The rest of the crew headed back to Chiang Mai but I stayed in Lampang for the night so that I could explore the city in the morning.

More to come...

Wats, Kao and scopes.

2009-05-09T23:26:00.006-05:00

Wat Chedi Luang is the biggest temple in Chiang Mai.

Kao niow moon muang, or sticky rice, sweetened coconut milk and mangoes. Very tasty!

Kansas style endoscopy in a far off land (Me and Dr. Yamada.)

Thai Residency

2009-05-07T23:21:00.004-05:00

So for the first two weeks I am working with the surgical residents here in Thailand (Me and Tar are pictured above). It has been fun learning the differences between our medical systems. First of all their medical school is based on the British 6 year model (similar to UMKC). So right out of high school they go to medical schools based on the entrance exams. So they may be as young as 24 when they graduate medical school.

Surgical residency is 4 years long here (5 in the US). However they don't have the same work restrictions as we do in the US. We are limited to 80 hours a week and 4 mandatory 24 hours off. They have no such restrictions and are basically on call every day for 4 years. I asked Max, the chief resident, if has time to go out at night. He laughed and said "Yes, when I graduate in one year."

The residents have been exceedingly nice to me. Picking me up when I get lost. Helping find my way around the hospital. To me it seems that the Thai people smile constantly. They also laugh whenever something goes wrong or you are doing something out of the ordinary. Well as you can imagine, I am constantly out of step with the Thai ways. So they are constantly laughing with me as I fumble my way through their culture and medical idiosyncrasies.

The medical care is very good here. They use the same ventilator that we do at St. Joe. They have CT, MRI, Nuclear medicine. They seem to be very up to date on all of the latest medical research. There is a public and private system here so all but the most expensive drugs and treatments are covered by the government here for the poor.

My time spent in the operating theatre (that iswhat the call the OR here) has been interesting for sure. You can imagine the first time I scrubbed in I was like a first year medical student fumbling and bumbling to get everything on. We'll start with the apparel. All of the drapes, masks, hats, and gowns are reusable. They don't use brushes to scrub in, only Iodine scrub and you have to use your elbow to get more soap from the pump. Also everyone wears little flip flops into the theatre. When I say little I mean like adult male size 8. My American size 13 feet don't fit into the little shoes at all. My feet actually hang off of the back by about 3 inches.

The scrub pants have to front or back. There is a pocket in the front and one in the back and a continuous circular loop drawstring. This is difficult to tie securely and the first time it took me like 5 tries to get them tied. I was eventually able to keep them on and proceeded to scrub in. After many smiles and snickers I was able to get everything on and I managed to make it to the patient while maintaining sterility.

This was the first night that I was here in Chiang Mai and the surgery was a 5 hour bowel resection/lysis of adhesions. Very meticulous and long case. Well about 2 hours into the case my poorly tied scrub pants started loosening. Before I knew it my pants were falling off underneath my surgical gown. When you are sterile you cannot reach below your waist because that is considered unsterile. I was able to catch one edge of the pants through my gown.

Now I could've broken scrub, pulled up my pants, retied them and then scrubbed back in. But that seemed very wasteful to me and they needed me to assist with the case. So instead I thought it would be easier to use a towel clamp to hold up my pants. Well I was trying to discretely get the scrub nurse to give me one but she couldn't understand what I wanted. Max noticed I was trying to get something from her and I had to let on why I wanted the towel clip. Everyone of course proceeded with the normal Thai laughter and the towel clip was then given to me. My pants dangled from the right sided clip for the rest of the case, but at least they weren't around my ankles...

Until the next adventure...

Monks, bells and long staircases

2009-05-06T12:48:00.006-05:00

The 309 steps to the Wat (temple), me and a random monk, Lizzy ringing some bells. (you can always click on the picture to see more detail)

Wat Phrathat Doi Suthep

2009-05-06T11:47:00.007-05:00

Dr. Greer took the crew (Me, Dave, Laurie, kids and Dr. Greers wife A) to a temple near Chiang Mai. (He is the one able to pronounce the temple in the video) It is only 30 minutes from Chiang Mai and sits on a mountain that overlooks the city. At the center is a large golden spire. It was built in 1383.

The legend behind the temple is as follows. There was a relic that was said to be Buddha's shoulder bone. It had magical properties and would glow or vanish. The king had the relic in his possession and it replicated itself. The king decided to build a temple for the relic and placed the bone on the back of a white elephant (I'm standing next to the white elephant shrine above). The elephant wandered for many days and eventually stopped at one spot, trumpeted three times and died. So they decided this was the spot for the new temple.

It has very nice views of Chiang Mai. It was a bit foggy while we were there but it was still very nice. There is a central wall around the inner spire with shrines encircling the entire structure. Outside the inner walls there are local people performing traditional dance and others playing with traditional instruments.

There are multiple bells and gongs that are available to ring. They are said to provide good luck to those who invoke their deep pleasing tones. There are many Buddhist monks at the temple of course. They are recognizable by their bright orange robes. Most men enter the monastery at some point in their life, even if just for a few weeks. Only some of them choose the life of a monk for life. It is auspicious to bring food and gifts to give to the monks. They will in turn bless you by sprinkling water on you. A monk may choose to tie a bracelet around your wrist which is a sign of good fortune.

There are some very ornate steps that lead to the temple. They have green dragons on either side and there are 309 steps if you wish to climb them. We had Dave's children there as excuse so we paid the 50 baht and took the cable car to the top. But we did walk down the steps on the way back.

There is a small town nearby and I ate some breaded, deep fried bananas that were amazing. They were probably very low in calories too... I'm off to bed. Must round at 7 am tomorrow.

Adios

Late Nights in Chiang Mai

2009-05-04T21:01:00.005-05:00

So after I got my sim card I called Max, the surgical chief resident. Max grew up in New York so he speaks very good english, but has been in Thailand for the last 15 years. He told me he would call me if any emergency cases came in. Well at about 7pm local time he called me in for some appendectomies that rolled in the door.

Well I got ready and left the hostel I'm staying at (the picture on the left is the view from my room). Mind you, this was the first time I was going to the hospital by myself. Earlier that morning Dr. Greer picked me up and took me to the hospital. By now it was dark as well so I was already lacking some of the visual cues that I had from the previous morning. I was sure that Dr. Greer had driven through this public park that is nearby the hospital. So I headed off into the park towards the hospital.

At night the park was much spookier than during the day. There are a few lamps along the way but not as many as one would hope when trying to find your way in the dark. After plodding along for 10 minutes or so I knew I was lost so I called Max. He told me to retrace my steps and gave me brief directions to the hospital from the hostel.

Well I was well into the park now and as I was walking by an expanse of grass I noticed there was a figure in the middle just standing there. This kind of freaked me out a bit so I decided to just head to the nearest lighted street that I could see. When I got to the street the entrance was closed with a large iron gate.

I looked back and the figure had moved. So I continued walking at a slightly accelerated rate down the fence line looking for a way out. I saw a walkway leading out of the park and thought that I was set. But that was blocked by a locked gate as well. In my mind I could imagine that this guy was probably sneaking through the woods about to rob me. So I resorted to climbing up on this pillar that was by the walkway. The problem was at the top were all of these bars that were meant to keep people from climbing over.

Well I guess my adrenalin was pumping pretty good because I grabbed hold of the bars and I was able to bend them to make room for me to squeeze through. Out on the busier lighted street I felt much safer. I then called Max described to him where I was (since I can't read the street signs) and he came and got me.

We ended up doing two appendectomies that were quick and then we had a 5 hour bowel obstruction surgery. We finished up at 4 in the morning and he was nice enough to drive me back to my hostel.

In retrospect the guy in the park was probably just doing Tai Chi and I am now a Thailand vandalizer. Hopefully I don't get caned.

Over and out.

Chiang Mai

2009-05-04T03:44:00.004-05:00

I arrived in Chiang Mai yesterday after the 36 hours of travel time. It was nice to sleep in a bed. Since the time is 12 hours different I did wake up frequently through the night and after 5 am I couldn't sleep anymore.

Since I did not have any obligations until 7 I was able to walk to the 7-11 and get some baht from the ATM. On the way I ate some food that was very similar to Navaho fry bread. It was a good breakfast and it only cost me 20 cents.

After that I went and met the chief surgical resident Max. We did some ICU and floor rounds on the post surgical patients. We then went to the outpatient department (OPD) and saw patients their.

Dr. Yamada is one of the attendings who specializes in upper GI surgery. She has a lot of patients who have had stomach cancer and she treats many of them with chemotherapy after surgery. We also saw 7 esophageal strictures today. That is more than my entire 3 years in residency. She says that there are a lot of esophageal strictures here because people often attempt suicide by drinking caustic materials like bleach or strong acid.

Well I am off to find a sim card for my phone so that I can keep in touch with the local docs.

Lag horn!

Bangkok

2009-05-03T02:32:00.002-05:00

Just Landed in Bangkok, Thailand. It is a balmy 95 degrees here. My flight from frankfurt was about 11 hours. The service on Thai Airlines was impeccable. They had dinner to us in less than an hour of take off. It was some very tasty chicken pan-aeng with sticky rice. They bring drinks around on these little platters and you just grab what you want. They come around about every 30 minutes with more drinks. Before I knew it I had a beer, champagne and a drink that I think was bitters and orange juice. All of these drinks are complementary of course.

This being the second night in a row that I have slept on the plane, I slept terribly. I think part of the reason is that my day and night are now flipped. Thailand is exactly 12 hours from central time (during DST). So it is 2:30 in the afternoon here and 2:30 in the morning back home. I think I am adjusting fairly well already though. Residency prepares you very well for chaotic sleeping schedules.

I am currently waiting for my connection to Chiang Mai. This is where I will be spending the month in the hospital. They are starting to board!

Lah Gorn!

Frankfurters, sauerkraut, heffeweizen.

2009-05-03T02:04:00.007-05:00

Ser Gut!

Frankfurt

2009-05-02T08:14:00.004-05:00

After leaving Chicago we were in the air for around 40 minutes before the captain informed us that we had to return to O'Hare. Apparently there was some problem with the cargo. That is all the information that they would give us. After about 45 minutes on the ground we refueled and we were back on our way. I sat with a Navy pilot during the remaining uneventful flight.

There was a woman with a baby that had perhaps the loudest cry of an eight month old that I have ever heard. That was fine, who can blame the kid, no one likes eight hour flights. What was really annoying though was that the kids mother. Every ten minutes she would repetitively sing “La La La la La la la la” to the tune of Twinkle Twinkle Little Star. The first couple of times it was cute but after the 743^rd time I was ready to start crying myself.

Well I did finally make it to Frankfurt. I have a 9 hour layover here so I decided to take a look around the town. Frankfurt is, of course, the origin of the frankfurter. So naturally, the first thing I did was to find some wurst. The street grill I went to put the long rindwurst in a small little crusty roll. The bread to sausage ratio was way off and it looked odd to me. However with a bit of German mustard it tasted just fine.

Well I think I will return to the hustle and bustle outside. There is a marimba band outside that looks pretty neat. Talk to you soon.

Ciao

O'Hare Airport

2009-05-02T08:07:00.001-05:00

Always a busy place. The tall vaulted glass ceilings in the international terminal allow copious amounts of light stream in. To me it feels almost as if I'm on a boardwalk admiring the shops among the sea of other travelers.
It always interests me to get to the gate of your eventual destination. I am always curious about the people that I will meet wherever I'm going. What will they be like, what do they dress like. Its at the gate where you get a prequel of these curiosities.
My next destination is Frankfurt, Germany. There is a German teenager nearby me wearing all black and acting goofy in front of his friends. The German language has the stereotype of being a harsh sounding language. Maybe it is a subconscious remnant of the time when we were at war. Call me crazy, but I actually think that it sounds nice. It does have more of a fricative nature to it when compared to English, but it has many airy, whooshing notes as well.
I am drinking a Goose Island beer right now called Matilda. It is a Belgian style Ale that has a nice malty front end and the finish is floral and mildly hoppy. Usually I'm not a fan of the hops but this is seems to have a good balance. I would definitely drink it again.
I never look forward to the 8 hour flights across the Atlantic Ocean. The seats are never quite as big as you remembered them. At least the international flights give you free adult beverages if you so desire. When I land in Frankfurt I plan on finding some wurst of some kind and maybe a large German pretzel. Time to board.
Aufwiedersen

The Journey Begins

2009-05-01T14:14:00.005-05:00

Well I am sitting in the Wichita Airport waiting for my flight to depart. I am off to Chiang Mai Thailand to spend a month working in a hospital there.

One of my fellow physicians Dr. Dave Larson is also going to be working there. He is traveling with his wife Laurie, a toddler and a baby.

I am not on the same flight as Dave and this is the first time that he has travelled with his children. I think that they will do fine I'm sure.

Chiang Mai is in Northwestern Thailand and is deemed the cultural capital of Thailand due to the amount of temples and sights around the city. It has a population of around 250k so it is good sized city.

Ok well more from the road later my flight is leaving.

Cheers.

Hyperinflation

2008-12-22T09:50:00.010-06:00

So as you may know, Zimbabwe is currently undergoing what is termed hyperinflation. This is basically inflation that has gone out of control. The economic reverberations from an unstable government has fueled this already unstable financial fire.

The current rate of inflation is 230,000,000% or 230 million percent. When the numbers on the bills get too large the central bank just hacks off zeroes (13 zeroes so far) from the end of the note. So the 1 million new Zimbabwe note is actually somewhere near 10 quintillion (that's 10,000,000,000,000,000,000 or 19 zeroes). To put that in perspective that is more stars than the entire Milky Way galaxy which has 10^9 stars. This number is impossible to understand for even the most educated of individuals.

Some of the obvious repercussions of this is that the money you have one day is not worth nearly what it was yesterday. The banks have limited withdrawal of money from the banks to 50 thousand Zim dollars in hopes of preventing runs on the bank. As a result, people spend their money as quickly as soon as they get any. This type of behavior actually makes inflation worse which partially explains the worsening situation. Basically the economy has fallen back to a barter economy where the exchange of goods ands services is replacing the exchange of currency. The US dollar is still widely accepted and is preferred to the Zim dollar by the locals. The problem is if you run out of US dollars the ATMs only have Zim dollars in them.

So overall this is a challenging time for the country and the hospital. Purchasing goods for the hospital has been problematic as well. Basics such as IV fluids have been difficult to come by. I hope that by the time I arrive in country the situation will have stabilized somewhat. We will just have to wait and see.

First Post

2008-12-16T21:48:00.003-06:00

Hey everybody. I am going to try to keep a blog to document my time overseas. For those that are interested in knowing what I'm up to, this will be a blog you can read to find out.

This will be my first real blog so hopefully I actually post frequently enough to make it worthwhile.

Thanks for tuning in. More to follow...

Rick II