Enough complaining.

Can't complain with this view. Currently at the beach, obvs. And now able to have a leisurely contemplation of this past week, without taking into account creature comforts and illnesses.
So about Sabana Grande, our community. It is about 5 hours north of Managua, high up in the mountains near the Honduran border. This particular community has a longstanding relationship with an NGO called Grupo Fenix, which has been working with community and US partners to promote solar energy. Most houses have some solar panels - enough to power one or two light bulbs, and some homes have solar "kitchens" aka ovens. Otherwise, the kitchens have varying degrees of ventilation, which is bad for respiratory health because they burn wood for fuel. Most families have multiple generations and several species of animals living together- cats, dogs, chickens, turkeys, pigs, cows. One or two families have televisions. Nearly every family as at least one cell phone. Our cell phone carrier is Claro (there are 2 major carriers in Nicaragua it seems), and they must have realized that the best means of advertising is through the cell networks so we are bombarded by promotional texts - e.g. you can win a Toyota Hilux! Buy minutes for 50% more today!
So speaking of the chickens, the roosters are out of control up here. They start crowing around midnight and don't really stop until well into the morning. Usually it begins with a distant cock-a-doodle-do which then starts a chain reaction with all of the nearby roosters. Sarah and I have conjectured that our family's rooster is going puberty as his squawk sounds a bit off, like he can't get the cadence right.
Rural medicine is challenging. Rural medicine in a developing country like Nicaragua is really challenging. We rotated with the local docs at their main clinic in Totogalpa as well as our "local" clinic in Sabana Grande. So the local/rural clinic in the community consists of 3 exam rooms and a room that they call a pharmacy, which is stocked weekly by the doc and nurses who come a few times a week. The first day of the week that the clinic is open begins with cleaning out the dirt and critters that have accumulated over the past week (this week we had a bat, several geckos, which were actually left mostly in peace). Then the patients line up for either "consulta" or "control" visits, e.g. urgent care-ish doctor visits vs immunizations with the nurse. We (Kay and I) saw 18 in 2 hours one morning, which is what can happen when you only have to chart the patient's information, diagnosis and write out prescriptions on scraps of paper. Most people don't have their own charts, and many forget even their ID cards. Lots of diarrhea (which is more likely parasitic than not- huge mental shift), headache, backache, allergies. Our greatest inadvertent booboo was giving metronidazole vaginal tablets thinking they were oral tabs.. hey we were just learning our way around the pharmacy, and dispensing our own meds (until they ran out anyway)! Clinic trash is thrown out in a pit outside. There is no running water, no thermometer for temps and otherwise we take our own vitals.
At the Totogalpa clinic, patients are vitaled and they have paper charts. So we saw a bit more chronic disease management... and the clinic ran until it got too dark to read the chart, because there was no electricity. There is a maternity center across the way where ladies come to nest prior to delivery, at about 39 weeks. Every night they all walk over to clinic to be checked to see if anyone is in labor, because if so, the clinic doc on call stays overnight.
There is a group of engineers from Dayton University here working on a solar autoclave, who plan on staying all summer. Apparently the university has been sending students for several years, and encourage global missions- it's a Catholic university ... so lots of folks around the solar center which has become our home base. We tend to hike down in the mornings (flushing toilets with seats are a big draw!) and also meet for a delicious plate lunch accompanied by a cold glass of juice (papaya, passionfruit, orange combo). As plentiful as the mangos are in the area, somehow we don't eat a lot of them... but we do eat the gigantic avocados which have a lovely mild taste (people have talked about importing these puppies to the US as our puny avocados look and taste like pale imitations). Oh and the coffee... delish.
I am looking forward to this next week when first year med students and my psychiatry colleagues join us- the more the merrier! And on that cheery note, I shall sign off for now. Until my next wifi access...

This is what paradise looks like...

Absolutely luxuriating in Leon at a fine hotel for the weekend. With our own toilet and shower with HOT WATER!!!!!

Survival!

Rural village survival tip#246: shut your head lamp off when using the latrine at night and you will attract less flies in the face as you try to do your bidness.

Next survival tactic to master - how to avoid getting bitten so much??! I think I can safely assume that I am getting bitten while in bed, given the locations of some bites - e.g. midriff, back, thighs which are always covered and actually, technically are with my jammies. Bed bugs mayhaps?

So. I survived my night of fevers, chills and vomiting. So now what? Hallelujah, we are going to Leon today so will be sleeping in a hotel with A/C and private bathrooms. I really do think, as Kay said yesterday, that though my heart is into this work, I just don't have the body for it (see bug bites and all manner of GI issues after 4 days here for further reference). Jungle vs Me... jungle 4- me 0.

I might be dying.

I cannot sleep. I'm having chills in tropical monsoon weather which is not a good sign. I am also trying very hard not to vomit. In my delirium of twilight sleep a few minutes ago, I somehow convinced myself that it was my job to stop feeling nauseated so that someone could get a nausea contract through.
Sarah has graciously shared her gallon plastic bags if it should come to it, as it is still pouring outside as it is wont to do most nights here.
I don't think I could want to go home any more than right now. If I don't make it, (insert histrionicity here) I hope that Andy and my family know how much I love them.

The best of times, the worst of times

Forty eight hours ago, I was in a food coma after the best meal of my life at a 2 Michelin star restaurant,  luxuriating in a spacious Jacuzzi tub in a lovely hotel room, accompanied by my loving husband of five years. Currently, I am sans hubby, lying awake in a creaky wooden bed listening to the torrential rain pouring down on the tin roof of this concrete hut, literally praying for God to ease my troubled traveler's bowels. Thinking back, I could have been more thoughtful about this transition to Nicaragua.
My host family seems very nice - nine members and three generations under one roof. My host mother patted my arm sympathetically today as she caught me coming back (again) from the latrine, aka concrete hole in the dirt, and told me she hoped I wouldn't have to go out in the rain. That makes two of us.
I find myself extremely grateful for small mercies - a functioning mosquito net, Imodium, and the fact that the 15 year old that I am chaperoning, for whom this trip is the first international experience, is sleeping soundly in the bunk next to me with no signs of illness. She is also adapting possibly more readily than me to this rural environment despite speaking and understanding very little Spanish.
Sabana Grande is a rural mountainous village in the northern part of Nicaragua, near the Honduran border. I will be here for 17 more days. Our baths will be from a bucket of unpurified water, and the humidity must be in the 80s or 90s. I have no access to electricity at the house. This is certainly not saying much, but I have never been this physically uncomfortable. I am not sure that I am made of strong enough stuff to thrive here. This will be my come-to-Jesus/Survivor/de-entitlement moment. Pray for me.

i heart P.E.I.

i recently read through the entire "anne of green gables" series by l.m. montgomery again, after discovering that the first few books were free on google books... luckily i got a chance to swing home recently, and was able to snag the few books that weren't available from our library. and though i do love google books on my phone and ipad, there's just something about the musty smell of my old paperbacks that is so... missed. evocative of earlier times, and an earlier, more innocent me with way fewer bags under my eyes.

reading the "anne" books was like having a reunion with old familiar friends. ms montgomery had this gift of creating these wonderfully fleshed out, awesomely REAL characters whose authenticity stands up even under the scrutiny of my now more-jaundiced psychiatrist's eye. she had a lovely way of describing humanity.

nice to know that some things do stand the test of time. nice to know that though many things have changed tremendously over these past 5 years of residency, 4 years of med school, and 4 years of college... some things haven't.

a letter to my 2011 self/2012 resolutions

dear self...

first, accept that this exercise is purely and embarrassingly self-indulgent, and the irony is that after plunging into the world of social media and in-the-moment self-disclosure, you're even less able to piece together a cohesive narrative of what has happened this past year. but somehow, it does feel important to try to put together a history of sorts because 2012 already feels like we're at the cusp of... something big.

this year was, like every other year, full of notable "firsts". first visits (and hopefully not last!) to greece and paris. first time serving as a matron of honor. first "real" camera. you and the hubs started making the inexorable (inevitable?) transition to the mac universe. first baby strawberries to survive the neglected garden. first trips to random norcal attractions- sonoma, muir woods, food festivals.

you were ambivalent about most of the notable "lasts". last family medicine call. last mommy call. last chance for a continuity delivery as a resident. there's also the looming, currently all-consuming question about whether certain events will have been the last time ever.... e.g. last visit to the state fair. last trip to apple hill.

professionally, it's been really gratifying to finally feel the years of training sink in and settle fairly comfortably. i have faith that we might just turn out ok after graduation. and waddaya know, it turns out that you don't hate teaching! you just hate teaching when you're frazzled and time-crunched and stressed out... but actually even then, it's not the teaching that's painful, it's the consequences of our inefficiency that kill us.

personally, i found it very enlightening that without trying very hard at all (though *ahem* you WERE supposed to be trying quite hard), you were able to drop some pounds. apparently, having most weekends free and bathing in the light at the end of the tunnel seems to agree with your metabolism. i hope to keep up the healthy habits that you tried to implement... and to ride your shiny new bike around more frequently.

so, bravo on getting us through this past year. things to work on in the next year... faith, hope and love. keep the faith even though the decisions that loom large seem completely beyond the ability of two mere humans to make with some measure of wisdom. work on your faith, now that you've been able to peer through the fog of cynicism. hope for good things to come, but work so that they do. and love- you could do a much better job of being a loving wife, daughter, sister... and particularly if there should be a significant move or change in the next 6 months, a loving friend. we've been blessed with wonderful friends, and it's always important to nurture those relationships.

here's to the year of the dragon.

love,

the (early) 2012 me

te amo paris

the hubs and i woke up at 5:30am the morning after we flew back to the states, jet-lagged and missing paris. so of course, i decided to go through our pictures from the trip and start to inarticulately record all that i loved so much. pictured above, two of my most favorite things about paris- walking along the seine at night, and berthillon ice cream/sorbet.

i would beg some consideration for the questionable coherence of this post however, given that along with some tasty souvenirs, i also picked up some kind of virus which is causing fevers and chills. but hey, remembering paris while in a feverish flopsweat is one of the more enjoyable things that i could be doing, all things considered.

we arrived at CDG airport early in the morning last thursday, and embarked on a whirlwind tour of the city of lights. we had 5 full days, but truly i think i would have liked to stay for another 5 weeks... months... years even! some scattered highlights/memory snapshots...

loved our little modern 1 bedroom apartment in the marais (3rd arrondissement) that we rented for the trip, decked out in IKEA-esque furniture and perfectly suited for our needs with laundry, kitchen, WiFi... we didn't plan on it being so warm (80s all week!) so ended up washing our "coolest" outfits over and over to reuse. cooked a few meals in our apartment, and got a small taste of what it would be like to be a local... which of course just fueled my city-living fantasies... for some reason, this dream of being a city-dweller dies hard.

we hit up the major touristy spots, criss-crossed the town on foot and have the blisters to prove it! next time, will be taking things a bit slower... and also will not be so delusional as to think that i could survive paris on heels of any kind. for some reason, in my head i saw all the women of paris walking around on 3 inch louboutins but i am here to say that about 90% of the women there wear FLATS. sensible women, them. anyhoo, on the hit list- eiffel tower, arc du triomphe, notre dame, place de la concorde, tuileries, luxembourg gardens, pantheon, opera garnier. on the museum list- the louvre, musee d'orsay, musee de l'orangerie, centre georges pompidou. we bought museum passes which were MONEY for bypassing long snaking lines of tourists, though there was no way to avoid the crush of humanity at the louvre for example- can't imagine what it's like to come in high season.

speaking of humanity, i really understood the term "unwashed masses" in paris. there are definitely looser standards of personal hygiene over there. and the bottom of the stairs at any metro station inevitably reeked of urine. no doggy poop around however, to the city's credit- that was one SJP/SATC moment that i did not need to relive ;)

oh the shopping. saw some of the chicest stores anywhere- colette and merci, but felt decidedly dowdy and old and uncool amidst the hipsters. i think i may need to undergo a makeover, post-residency... funded by my post-residency income. marveled at le bon marché, paris' version of neiman marcus and le grande epicerie which is paris' version of eataly. saw the original chanel store and the famous staircase (but was not allowed to take pictures). walked rue saint-honoré, and various other trendy streets for shopping in the marais. such motivation to lose enough weight to fit into couture!!

speaking of losing weight though... i now come to... the food. i'm truly finding myself inadequate to the task of documenting what was an amazing culinary experience. the hubs and i kept saying to each other that this or that was "the best thing we've ever had", and also remarked emphatically that "we can never go back" to "regular" food. as anyone who knows me might have guessed, our food options were the most researched aspect of our itinerary. i put my admittedly weak-sauce excuse for a diet on hold for the trip, and ate guilt-free. had the most amazing croissant, pain au chocolat, and madeleines at blé sucré. scored lunch reservations at chez l'ami jean for an inventive, rich, delicious introduction to basque-style cuisine- wonderfully complex soups, perfectly cooked duck and veal, unique and balanced desserts including a pumpkin concoction that i still think about. had lunch at spring restaurant, and made friends with the chef, a darling of the NYT- eating at the bar by the kitchen was such a cool experience. Chef Daniel Rose himself would describe each of our dishes, actually was very kind about our dietary restrictions, and was overall a perfectly gracious host. We were able to see the effortless ballet that his chefs performed while pumping out exquisitely cooked food... oh man, it really was a foodie's dream. even our unplanned meals turned out to be great experiences as well though- dinner was frequently some store-bought paté or foie gras with cheese and a fresh baguette, or stopping at a local bistro. one thing that i found fascinating though was how apparently most parisians finish their entire plate, because i got multiple worried comments from the waitstaff when i would leave any food on the plate... so apparently portion control when eating out is NOT one of the tools employed by famously slender parisian women.

my quest for the best macarons in paris deserves its own paragraph. i must say, i failed to visit all of the patisseries and bakeries that i intended to visit, for lack of time/planning so i consider my evaluation incomplete. however, i can say this much- i don't think there is such a thing as the BEST macaron, as i found that it is highly flavor dependent. pierre hermé had the best caramel macaron, while the overall best macaron that we had in paris was the orange-ginger at jean-paul hévin. ladurée offered solid, work-horse-like options for tasty macarons. angelina and michel cluizel both had good macarons as well... and i didn't get to try gerard mulot, which is also batted about when talking about the "best" in the city. all the more reason to continue my quest in the future when i come back (not if, WHEN)... also, i have many many flavors left to try from berthillon ice cream/sorbets...

another thing i loved about paris.... people just LOUNGE there. we took the bateaux mouche boat ride on the seine at night, and saw scores of young people just chilling on the banks with their friends. ditto for any gardens- luxembourg, tuileries, in front of the louvre... people just sitting and talking, lovers canoodling, families spending time together. it was lovely, and i can't really think of an equivalent here in the states... but there should be, i think. like, the big plan for friday or saturday night is... just to hang out and talk, in a lovely outdoor environment. i like it.

so, i took a year of french in 3rd grade which has left me with the ability to count to 10, and parrot a memorized "conversation" consisting of questions and answers to "what is your name?" and "how are you?"- essentially, totally useless. the hubs took french in high school, but his retention of any such skills is self-admittedly abysmal. luckily most people in paris speak english, which is good because any attempts i made at making simple conversation invariably led to some spanish sneaking in there. for example, water "sans gas" became "sin gas". "ouí" became "sí". i was reminded of one of my high school spanish teachers who also taught french, and frequently had this problem... i don't know that my brain is able to retain working knowledge of more than 3 languages, but i'm eager to try... whenever i can afford that darn rosetta stone software.

suffice it to say, i'm hungry for more paris. i loved it, and i want to go back in a way that is wholly atypical of how i've felt about my other travels. i hope this is the start of a beautiful friendship...

a day in this life...

i find that my memory fails me too often... certainly more often than i'd like for someone under 30. and i'm starting to realize that as my residency draws to a close, i really probably won't remember very much about what it was like apart from vague nostalgic fuzzy bittersweet feelings. so, i'm going to make an effort to document this year in mental snapshots. today, for example...

8:05am- walk in (late) to huddle in clinic where i catch the tail end of a discussion about a recent article documenting anemia due to blood draws in the hospital.

8:15am- am told by my MA that a mien interpreter is not available until noon (while my mien-speaking patient has just been roomed). luckily, i grab another MA to serve as my interpreter to avoid yet another appointment carried out largely with awkward gestures (e.g. how does one ask about hemorrhoids?) and slow, loud talking in an attempt to somehow make myself more understood (which reminds me of an appointment i had with a deaf patient and his sister, who claimed to be an interpreter and whose claims i gradually started to doubt as she basically used the same rudimentary/universal body language/signs that i might have used while again talking loudly and slowly)

9:00am- get an inbox message saying that my nursing home patient, whom i saw last week after she was discharged from the hospital, has been readmitted with a stroke. she's now nonverbal and on comfort care. i'm never going to have a conversation with this lady again.

9:10am- carry out extensive discussion about contraceptive options with a new patient, whom i'll follow for all of 10 months before passing her off to a colleague as i leave. she seems nice, i'm sad that we probably won't see each other very much before i graduate.

9:30am- go out to mollify a patient of mine in the waiting room because she's been waiting 30+ minutes while her insurance status gets sorted out, and at this point i need to reschedule her. she says, "I need meds!" and i oblige.

... and so on, and so forth- i use my breaks in between patients to check emails, send yet another reminder email to my combined residents to RSVP to some event, switch a call, drop off a triplicate, call patients back, write notes, etc... though before lunch one highlight was that i did get to freeze an actinic keratosis off an attending.

12:15pm- i rush out to the cafeteria to grab a sandwich and travel over to the county psych clinic where i'm finishing up a 2 month stint. along the way, i tweak my ankle while navigating a tricky patch of soggy grass in my wedge heels.

12:30pm- utter panic. my computer has been replaced with a shiny new one. which would be otherwise very good news as my old computer operated at the speed of dial-up, however this is NOT good news because i had not backed up my patient files that are sitting in a folder on the desktop of said old computer. a flurry of desperate phone calls to IT ensues. meanwhile, i listen to several messages on my phone from this morning- a typical example: "uh, dr park, i really need to talk to you about my depakote, ok? because i think i might have a seizure and i'm almost out of the medication and the pharmacist told me not to take the medication that you gave me, so i don't know what to do! call me back, ok? please call me back!!?" (note, i am not practicing neurology).

1pm- time to see a new patient!

2pm- new patient out the door, and i'm frantically limping as i haul (haulping?) computer towers that look like the one that was in my office back and forth from where they sit in anticipation of exile to my office. dangit, the new monitor doesn't work with the old towers! i bring back another monitor as well... dangit, it doesn't have the power cord attached! i bring back yet another monitor... and try a tower... and another one... and another one... [life lesson learned- BACK UP FILES]

2:45pm- sweaty, covered in dust, but triumphant. i think i might survive the last few days here in this clinic. next few hours until 5:30pm spent seeing a few patients, writing notes, printing notes, sticking patient labels on notes, fielding telephone calls, faxing refill requests, reviewing labs, punching holes in all papers to put into paper charts, checking my OTHER inbox to make sure it's clear, etc.

... and now, here i sit at midnight, unable to sleep because like an insane person, i never learn that caffeine post-5pm results in insomnia, and the aforementioned gimpy ankle is protesting with the slightest positional change. and that, is another day.

hello, goodbye

who decided that may/june would be a time for graduations and weddings? and whoever decided on making the start date for residency around july 1st? it makes for a really busy, bittersweet season. hello to new interns, celebrations for new married lives together, but goodbye to friends who are moving on. above, a brief pictorial spread of the graduations from this season- so this year, we hit up our family medicine and psychiatry graduations, as well as the hub's old residency graduation, in addition to our "combined" graduation/BBQ. congrats to all the new grads!!!

all of this graduating makes me really antsy to do the same. *sigh* one more year to go.