The first two weeks of the rest of my life

**Late post** I started working as a family medicine doc for the first time since residency last week, and for the first time ever as a graduated board-certified one. Prior to my first shifts I had a lot of apprehension and anxiety, which I vocalized quite vociferously and indiscriminately, but now that I'm into my second week I thought I'd document some thoughts on this transition into "attending" life.

1. Family medicine, quite simply, is the bomb. I am so happy to be seeing the full spectrum of snotty-nosed kiddos to spry old folks in wheelchairs. I had a long discussion about breast health as related to breast feeding which led to a discussion of introducing solids and parenting at large the other day, and thought - man, I'm so lucky to get to see and treat and learn about pretty much the entire gamut of human health. A scheduler at one of the clinics came by and said, "I heard you'll take anything with a pulse!" To which I replied, "Yup, even the ones with two!" However, that being said...

2. Family medicine is freakin' hard. I've had many encounters over the past few weeks where I've had to discreetly excuse myself from the room to run into my office then frantically look something up or call a specialist to ask a question... Not because my skills are rusty, as I feared before I started, but because it's stuff I'VE NEVER SEEN BEFORE! It's challenging and frustrating at times and humbling... but I'm always learning something new. I suppose there's an extra tinge of fear or apprehension now that it is my own license on the line, as opposed to an attending's, but to be honest I don't think about it very much... Which perhaps speaks to my level of neurosis and anxiety about patients even before my career was on the line with every independent decision I make :P

3. Per diem is great in terms of finishing notes on time and getting out on time but... I miss continuity. I want to see what happens after I've ordered that scan or referral, and I wanna know that my patients got better. I want that feedback in terms of the technical aspects of my craft, but also as a means of developing that most important piece of being an effective physician- the therapeutic alliance. I'm okay with not having an inbox though. Waaaay okay with that.

sorry Thomas Wolfe, but you can indeed go back home again

The definition of a first world problem: I don't think that my kids will be inspired/humbled by my gritty tales of growing up as a privileged upper middle class brat in Orange County, the way that I am by my father's tales of growing up as a street urchin in Pusan, trolling the crawlspace under buildings for stray pennies.

It seems that my life is full of these first world problems since moving down to SoCal... I gripe about non-open-concept floor plans and perseverate about which of my many part-time jobs I'd like to keep or cut. I enjoy grousing about things as (globally) insignificant as traffic or the Santa Ana winds which mar otherwise perfect sunny 75 degree weather (in January).

All this to say that I am self-aware enough (just barely) to realize that I'm monumentally blessed to have only such matters cluttering up my consciousness.

My new year's resolution? Thankfulness and gratitude on a moment by moment basis.

welcome to SoCal?

The scene: our local Home Depot, in the kitchen section. The hubs and I are excitedly discussing countertop options in an insufferably yuppie/wannabe-hipster fashion, e.g. "They make recycled eco-friendly options?! Awesome!!" or "I really do prefer the look of granite..." A Random Home Depot Dude (henceforth referred to as RHDD), a petite metro-looking young male, approaches.

RHDD: Excuse me, are you interested in remodeling?

Me: Oh, maybe eventually, but we're just looking around.

RHDD: Do you own a home?

Me: [thinking that these are intrusive questions and hoping he will just get to the point] Not yet, but hopefully soon!

RHDD: Do you know who I am?

Me: ... [should I?]

RHDD: I'm the guy from the Home Depot commercials.

Me: ... Well, we just moved down here so if they air locally, we wouldn't have seen them.

RHDD: No, they're national...

Me: ... [awkward pause]

RHDD: Well, it's okay, I'm not that much of a celebrity. Anyway, you just missed out because I'm giving away free designer packages for remodeling.

Me: ... uh, okay. ["that much"?? who are you??!]

RHDD: Alrighty, you folks have a nice evening.

The RHDD strolls away, ready to accost another innocently browsing customer, and I am left to wonder... even Home Depot employees in SoCal are aspiring actors???

ugh.

moving is the WORST. this is a snapshot of the general state of disarray that is reigning over the Park household at the moment. even though we are taking advantage of a professional moving service for the first time ever, courtesy of hubby's new gig, there is still so much to do! organize, sort, throw away, donate... and, this is our most epic move ever, given that neither of us has ever lived in one spot for this long. the sorting process has led to accusations of packrattery (I just made that up) aka hoarding on both parties, yet strangely not accompanied by any actual action (i.e. throwing things away) to refute such claims. thankfully, my long-suffering and ever-loving mother came up this week to help with the process and took matters into her own hands, so I may never know just how much got tossed out... which is probably for the best.

to make matters worse, I was hit with what may have been the most painful 24-hour bug of 2012 yesterday, which incapacitated me during this crucial pre-move week and prevented me from spending this precious remaining time with friends. I had flashbacks to my bout with dysentery in Ecuador... it was that bad. however clearly I'm recovered enough to blog about it cheerfully, and am hoping that I'll be hale enough to weather the rest of this move.

in other, more maudlin news, I was reminded of just how blessed our family has been over this past weekend after spending time with some of our closest friends. I remember distinctly worrying when moving up here that I would never find the kind of friends I've had the privilege to have- particularly after the warm, fuzzy cocoon of Loma Linda. And yet, five years later, I'm leaving Sacramento firm in the knowledge that we've made friends for life up here... people that have enriched our lives in so many ways. ugh. so maybe what I mean to say is, saying goodbye is the WORST.

adventures in oz

so you know that old bromide about moving away to another country if a particular party/candidate wins the election? well, I must admit that I use it all the time, probably too much and disingenuously at that. anyway, the countries that I choose for this fantasy have been New Zealand or Australia... because Canada is too cold. Also, I took a trip (Korean tour) of the lands down under (+Fiji) in med school with my family, and just loved it. so when the hubs and I were debating where to go for our two week vacation (to celebrate end of residency, finishing boards, pre-move to SoCal, etc...), I was more than willing to go see Australia again.

I'm happy to say that I would indeed move to Australia, irregardless of whatever potentially disastrous political turn this country makes, because it is, quite simply, awesome.

But you know what's not awesome? Trying to write a travel journal > 4 weeks after the actual trip. As jazzed as I am/was about our travels, the further out I get, the less inclined/motivated I am to document things to the level of detail I would like to maintain in order to evocatively memorialize all of the fabulous moments we experienced. Yes, I do hope to look back on this blog in 10+ years, using the holographic display embedded into my retinas ("Google Retina"), and somehow be transported back in time and space by nothing more than my highly specific words. So, that isn't going to happen... and by "that", I'm referring to my words, as I'm very confident that Google has such a thing in the works. (note to self, blog in real time! face palm.) Instead, I present- my hodge podge impressions.

Our first few days in Oz, back in mid-September, were spent in Sydney, New South Wales. It is a gorgeous, sprawling city with tendrils splayed out over its many-fingered harbor. Our hotel was off of Campbell Street in the Haymarket/Chinatown neighborhood, so we had a chance to really explore and eat our way through Sydney starting there. Some highlights: sitting in on a parliamentary session at the NSW Parliament and appreciating the refreshing repartee that comes with a Westminster system of government. Walking everywhere - along Darling Harbour, through the Royal Botanic Gardens whilst visiting museums and monuments, up to the Rocks, down through the suburbs of Surry Hills, amidst tranquil waterfalls and pagodas in the Chinese Garden of Friendship. The stunning vistas from Taronga Zoo across the harbor. Haute Australian cuisine with a view of the harbor at Quay Restaurant. Beautiful historic buildings passing as malls, crammed with little boutiques and shops. Gigantic serpentine malls with entire floors of unique culinary options passing for food courts.

I really could wax rhapsodic about the food, or at least attempt to convey the depth of my feeling about our culinary experience with these paltry words. Our very first taste of Australia- fresh, buttery, flaky roti with succulent satay. The ice cream jackpot of goodness beneath a brulée-d shell that is Peter Gilmore's snow egg. Steamy, pillowy fresh chicken bao. A hot dog elevated to something else entirely (something BETTER) with mushy peas and mashed potatoes. Lychee gelato, practically sparkling on my tongue. Scrambled eggs as I have never had them before, transformed into silken richness on a fork at bills restaurant. And those are just the food memories from Sydney.

Cairns was a great base from which to explore the Great Barrier Reef and the surrounding rainforest. There is such a diversity of experience within the vast continent that is Australia, which was exemplified with our range of activities over the two days we spent in Cairns- one day we explored the reefs, snorkeling and hanging out on one of the many islands dotted across the Reef. The other day, we hiked in a rainforest and rode an army duck (amphibious giant jeep) through a river, with nary an ocean wave in sight.

I realized something whilst snorkeling- I am scared of the ocean. Despite being a fair swimmer, I asked for a life jacket and also clung desperately to the life preserver ring that our guide towed behind him. There was something very reassuring about bobbing close enough to the ring to be smacked in the skull occasionally while looking down at the reefs. I hope to someday push back against this fear- I think it's a little too ambitious to say I will overcome it entirely- and try scuba diving. Or even just snorkeling without a jacket! I do also need to learn how to use fins appropriately. Half the time I was froglegging it, and the other half slapping my fins ineffectually atop the water. So maybe I exaggerate when I say I'm a "fair" swimmer - heh. All of that being said, there was no greater distraction for my aquatic incompetence and fear than the teeming abundant life of the reef.

Thoughts about Melbourne and Brisbane to come...

at the close of summer

so what do I have to show for the first two months after a 5 year residency? these months about which I had dreamed and fantasized for such a long time... like, five years. :p Turns out, a mixed bag of business and pleasure.

as I am fond of lists, a few highlights:

"We flit, we float, we fleetly flee, we fly." DC, NYC, Vegas, SoCal, SoCal again, Michigan (Detroit, Mackinaw Island). Lots of daytrips to the Bay Area. Upcoming tour of Australia. Good times all around, and to come.

"Make new friends, but keep the old." It's been so, so very nice to reconnect with med school, college, high school friends this summer. In almost every case, it's just been a matter of picking up where we left off... i.e. before residency happened.

"And I was like, baby, baby, baby, oh." I've really missed spending quality time with babies outside of work. I mean, time spent with babies at work can hardly be described as "quality". Luckily, there's an abundance of perfectly adorable recently-produced babies whose parents aren't opposed to letting me hold them for a bit. And just to clarify, this is not baby fever, as I am happy to give them back.

"Eat your salad, no dessert." Thanks to Jennyfur's recommendation and the MyFitnessPal app, I'm calorie-counting for the first time ever! Though it's a little too late to "get right for the summer", it's not too late for summer 2013! Hope springs eternal.

"Is it worth it, let me work it." As a result of putting in time at a start-up, I've gotten my first post-residency business cards, been in an "industrial shoot" for a promotional video, and learned more about the state-to-state inconsistencies in involuntary hospitalizations/duty-to-warn/APS/CPS/IPV reporting than I ever thought I would.

"But still you're in my way." Why has the ABPN decided to offer the board exam in September? Why can't it just be over and done?! Why is it so difficult to study??!

"Woke up on the right side of the bed." I think I've finally shaken off the sleep debt. Feels good.

Insight(s)

Aka things I have learned while on the "psych" portion of my trip, which began last week upon the arrival of my fab psych colleagues and travel buddies Sarah and Amy.

1. Food allergies are a first world problem apparently, which may or may not be due to rampant parasitosis in the developing world?? This insight arose out of a lively discussion about whether or not gluten allergies were code for an Axis II diagnosis with the owner of the surf/yoga eco-resort where we crashed over the weekend. He has to deal with many anxious gluten-sensitive women who come for yoga retreats in particular, and had surveyed the locals who reported no food allergies whatsoever. He ended up explaining the gluten/lactose/non-hypoallergenic soap "intolerances" to the confused local staff as "illnesses of the mind".

2. Being American has its perks. We three young American women, dressed in casual travelling-style, marched into clinics, pharmacies and even deans' offices at the local medical school, declared ourselves to be American doctors and miraculously people listened to us! We mused about how differently things might have gone if the situation had been reversed... if 3 young Nicaraguan women speaking broken English demanded an audience with, say, Dean Pomeroy at UC Davis. Yup, good to be from the US of A sometimes.

3. Carsickness becomes exponentially worse when packed like a sardine in the aisles of a humid bus, and nearly unbearable when it starts to rain thereby forcing everyone to roll up their windows and creating a nightmarish sauna-like environment. It does improve when your travel partners notice your pale, diaphoretic, swaying state and swiftly switch you to a spot by an open window. Getting pelted by rain is a bonus, though the mom of 3 adorable little girls who were sitting in the seat by aforementioned window was very sweet and provided one of the girls' jackets to shield me. Very kind, despite my gross invasion of the girls' space in my blind desperation to catch the breeze and avoid vomiting. Can't imagine what they must have thought as they stared up into my foreign misery-stricken face, looming above them from behind the chair with eyes tightly clenched.

4. Air conditioning is one of the top 10 best inventions ever.

5. Antimalarials really do cause vivid dreams! Though sharing those vivid dreams may just lead to merciless teasing for the duration of the trip...

6. Describing cock fights in English is a filthy, filthy endeavor. Also, saying the words in English (after being informed about the double entendre) can be a source of endless amusement for straight-laced, middle-aged, very educated Nicaraguans.

7. Managuan traffic is worse than LA traffic. Impressively so. And all the harder to navigate because of the lack of street names.

8. Frolicking in the ocean can be fun and not terrifying! I have Sarah to thank for that insight (thanks Sarah!)

9. Thunderstorms and lightning are no joke. Now I understand why Julie Andrews and the Von Trapps came up with the "Favorite Things" song. Also, the saying "when it rains, it pours" finally makes sense to me after many nights listening to torrential assaults on the roof.

10. The themes in The Hunger Games can be applied to nearly anything in life. Also, appreciating the 2nd and 3rd books requires "intellectual integrity".

11. Stuffed churros rock.

12. I have had enough gallo pinto (rice and beans) to last me multiple lifetimes.

13. We are lucky to have whatever regulation the FDA provides... Nicaragua has no Haldol in the country, after the last few batches from India or China caused people to have more hallucinations.

14. I am a city/suburban girl, full stop.

15. I am pretty much done with residency.

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.