Intern Year

Intern year ended a little over a month ago and already I'm caught up in the bustle and newness of being a junior resident. I had intended to write some reflections on the year earlier, but am just now finding the time to sit down and really reflect on the importance of what has happened to me over the last year. Briefly summarized, I have seen over the last year that the time for me to grow up has finally come.

I entered residency cautiously confident, believing that I had been adequately prepared, that I had much to learn and that I would do the right things at the right times. Over the course of a year, through poor decisions, false perceptions and inadequate knowledge, I have learned that the complexities and intricacies of dealing with sick people are beyond me. The year was a cycle of gaining ability and confidence only to be forcibly reminded of my inability by sobering mistakes.

The need for help
Self-deprecation is not my goal in writing, for I sincerely believe that I will develop into a capable, even possibly excellent, surgeon and doctor; however, I have not yet arrived. Despite my constant desire to question the edicts dispatched by my superiors, I now trust that I need their guidance and teaching more than ever. Many of my mistakes could have been avoided if I had asked for help sooner rather than later.

The need for caution
I sincerely believe that things will turn out for the best in all circumstances. Whether this is a byproduct of my upbringing, a facet of my faith in God, or simply a hopeful desire, I do not know, but while a joyful and good character trait, it can predispose to danger. The truth is that things don't always turn out for the best, particularly when dealing with sick people. Sometimes they take a turn for the worst possible outcome and my work is to guard against that possibility, even while hoping for the best.

The need for discipline
Now this is what I mean by growing up: Not giving up joyfulness and excitement and adventure, but by recognizing the proper time and place for such things. My last post hints at this, but explicitly, I can't achieve excellence on talent alone. To truly love my patients requires sacrifice. To truly love God requires sacrifice. To that end, there are days when I will want to go play, but when duty necessitates discipline and study. There are countless mornings when I want 10 more minutes of sleep but when dedication to God demands that I get my butt out of bed and spend some time in prayer and in the Word before I am ready to face the day.

The need for humility
All the above culminate in a concerted effort to take myself out of the middle. The tendency toward an attitude of self-preservation is so strong in residency that it can overwhelm all other desires and dreams, but it is not an unconquerable urge. When I stop trying to take care of myself, every controversy above resolves and the need for sustained effort transitions seamlessly to an outpouring of other-centered goodness. The only way I can practically achieve this in my mind and in my life is to be fully confident that in neglecting myself, God will provide. In fact, this is the challenge to believers for generations past and will continue to challenge us for as long as the war between selfish desire rages against love.

Therefore if there is any encouragement in Christ, if there is any consolation of love, if there is any fellowship of the Spirit, if any affection and compassion, make my joy complete by being of the same mind, maintaining the same love, united in spirit, intent on one purpose.

Do nothing from selfishness or empty conceit, but with humility of mind regard one another as more important than yourselves; do not merely look out for your own personal interests, but also for the interests of others. Have this attitude in yourselves which was also in Christ Jesus, who, although He existed in the form of God, did not regard equality with God a thing to be grasped, but emptied Himself, taking the form of a bond-servant, and being made in the likeness of men. Being found in appearance as a man, He humbled Himself by becoming obedient to the point of death, even death on a cross.

For this reason also, God highly exalted Him, and bestowed on Him the name which is above every name, so that at the name of Jesus EVERY KNEE WILL BOW, of those who are in heaven and on earth and under the earth, and that every tongue will confess that Jesus Christ is Lord, to the glory of God the Father.

The Next Step

It's been a pensive day. Lots of things have converged lately prompting me to take a census of what's going on with me, God and life. And it's been good. Real good. I don't really write on here anymore, but today was one of those days when I felt like writing.

If you haven't been around, my journey for the last several years has been centered around the realization that God is among us, active and hopeful that we will lift our eyes from our own lives and join in the story that He is writing in the paths that we walk. That prompted some reevaluation of my spiritual beliefs and practices resulted in the exploration of true freedom, relationship and service to others. It has been a joy to discover new ways to glorify God, to feel myself slowly unburdened from the legalism that so often accompanies religion and to see prayers answered, whispers of God in all things and meet others in whom Christ so obviously dwells.

In the midst of that learning, I was learning to experience God through enjoying good things in life. Now unfortunately, I may have associated things like skiing, rock climbing, good music, food and beer with carrying out the simple call of Christ a little too strongly. All beautiful things to enjoy, but lifeless in and of themselves and missing pivotal elements of the life of Christ. I still can and will enjoy all those things in life that God has gifted to us, but those things can't be at the center. I don't know what it was today, but I was reminded of my first steps toward a life lived fully with God. Back then, I was miserable but found simple joy in working for the happiness of others. It happened in Guatemala and continued in Texas and then Alaska and so forth.

A lot of people ask me how I like living in New York. Those from Alaska (including myself) sometimes have a hard time understanding how I can be happy somewhere so far from home. The truth is, my happiness, my joy, even when I was there, was never about the mountains, the wilderness, or the exhilaration of extreme sports. Rather, the joy I experienced occurred secondarily to taking myself out of the center and using my life to build up others. Even good things can become idols. It is the recognition of where God is moving and joining in that brings joy, not in recreating the specific context of where or how He has acted in the past.

I've learned well over the last few years how to live, how to love myself. I see this as a dangerous destination if viewed as such, but as a necessary precursor to the next step. To love your neighbor as yourself, you necessarily must love yourself first by understanding the great love that God has for you. I am here in New York not only to live life to the fullest for me and for God, but to live fully and to share that richness with all those around me in simple acts of service.

"Teacher, which is the most important commandment in the law of Moses?"
Jesus replied, "'You must love the Lord your God with all your heart, all your soul, and all your mind.' This is the first and greatest commandment. A second is equally important: 'Love your neighbor as yourself.' All the other commandments and all the demands of the prophets are based on these two commandments."

Leaving Peru

As a rule, I hate leaving. Maybe it's just me, but I think at some level, we realize that we were not meant to be apart from those we love. Yet another little cue that points my eyes toward God. All that to say, there are some really wonderful people that I will miss having left Peru. I love the diversity and unique personalities that you encounter when outside your element. I also love friendships that grow quickly and the ability to create lasting bonds in such short time.

Early in my trip, I started compiling some unique things about Peru, some serious, some not so much. This is what I came up with:

Everything means something else/is innuendo
I realized quickly that I had to be really careful what I said here. Almost every word in Spanish means multiple things. Sometimes, this only creates a sense of confusion for the gringo that doesn't understance the nuances of the language. Other times, it creates for particularly embarrassing circumstances.

Not all parts of speech are mandatory
Now this may be true in English also, but I found it particularly challenging that a sentence could contain neither a verb or a subject and everyone else in the room would understand exactly what was going on. Not me. A simple prepositional phrase is not sufficient. But toward the end of my trip, I started doing it too.

Peru is not a poor country
There are some incredibly poor people here, but I was struck by the diversity of agriculture (read POTATOES), commerce and industry here. This place is rich with resources and has fairly decent infrastructure. It also has room for development, which I think we will see in the coming years. Unfortunately, Lima has had a HUGE influx of indigents and there is a real need in the surrounding areas.

Oompa loompas are real
I couldn't resist a dig a this, just because it cracked me up and made me happy so frequently. One of the first sights I saw arriving in Peru was a VERY SMALL person cleaning the sidewalk. As time went by, I adapted to the fact that it is very common for indigenous Peruvians to work in city improvement, but I SWEAR that they hire the smallest people they can find for the street sweepers.

The sun really is hotter higher up
Oh the burning. THE BURNING!!

Latin Americans really can dance
I'm sorry, but what we do in the U.S. just isn't dancing when you compare it with Latin America. I had a ton of fun not only trying to not move like a gringo, but just watching the people dance here. They manage to be really smooth and sensual without being hypersexual (if that makes sense). Not to say that everyone at the clubs was a Puritan, but the mood was different for the most part.

Plans don't count for a lot
I found it was quite possible to agree to a course of action with some one else, only to find out in hindsight that they really weren't totally serious. I never quite figured this one out, but it seemed like sometimes you made plans and they happened, and sometimes, they just didn't count.

In medicine, sometimes less is more
I can't contest the fact that the U.S. has amazing health care for those that receive it. What amazed me here is that everyone gets treated at least to some extent. The ugly side of U.S. medicine that most people don't have the privilege of seeing are those patients with potentially curable diseases that are working to make ends meet as it is, and then get diagnosed with something terrible. While that can still be devastating here, it somehow seems more recoverable. There is clearly a lower level of care delivered to the working class here, but rarely is some one simply denied treatment.

God is always moving, you just have to look
While I didn't have a particularly moving spiritual experience here, there were definitely some sweet times of communion with God in a very unique part of His Creation. There were chance encounters with folks doing their small part to demonstrate that God loves all people, not just those with money, and a lot of wonderful relationships formed here. I know that leaving Peru, I feel closer to God and more in tune with His plans and wishes for my life. It has been a sweet time and I am excited to see what Costa Rica will bring.

A case or two

I can't stress enough how strange and interesting are the cases I see here every day. Probably kind of boring for most folks, but I wanted a record of what I had seen. Here's a brief run-through of a few patients on our ward right now.

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Typical TB patient being treated for about 3 weeks turns yellow, gets nauseous and shows up at the hospital. Lab tests confirmed our suspicion of a drug reaction, so all TB meds were stopped and we're waiting for his symptoms to improve before restarting.
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26 year old with fever & chills off and on for about a month. Enlarged liver & spleen. Initially responded to treatment for malaria despite a negative blood smear, but fevers returned every couple days. CT of the abdomen was bland. We still don't really know what's going on with him, but are suspicious for malaria resistant to chloroquines.
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Snake-bite patient came in, but other than a little pain, he's done well. No massive necrosis or infection.
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A 16 year old kid supposedly kicked a soccer ball a week or two ago and developed an ulcer and subsequently and necrotizing skin infection. My friend working in the lab cultured out Pseudomonas, a bacteria that is really rare in healthy patients. This kid's foot looks pretty bad now, but it should be getting better over the next couple days.
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We have a couple patients with HIV & some type of secondary infection. One is a 22 year old with Kaposi sarcoma and meningitis. Another, a middle-aged guy with cryptococcal encephalitis that isn't doing so hot. The third is actually comatose and found down by the police. We're presuming he has meningoencephalitis tuberculosis. Tragic patients to work with really.
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Also had a fascinating/terrible case of leptospirosis with scleral hemorrhage, liver failure, kidney failure, hypocalcemic contractures and ridiculous amounts of jaundice. With this severity, it's called Weil's syndrome. He's actually doing better now too.

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Occasionally we get consults from other departments, this time it was peds. The patient was a 24 day old baby born in a village to a mom with malaria. She became deathly ill and was taken to the hospital while the baby stayed at home with grandma. Mom got better, but at 21 days, the baby caught fever, his blood pressure dropped and he was taken to the hospital. The typical test for malaria here is a blood smear, which is rated on a scale of 1 to 4 pluses. This kid had a 4 plus blood smear, a ridiculous amount. With the timing and the level of parasite load, it is almost a guaranteed case of congenital malaria, an incredibly rare occurrence. My attending had never seen such high levels and will be submitting a paper to describe the case, as it is rare even with low levels. They have designed a treatment regimen here that seems to be working and the baby was much better today.

Fin de semana #6 - Man Versus Wild

Okay, so my Amazon jungle experience wasn't quite that hardcore seeing as I had a guide and a roof over my head, but despite not being totally swarmed by mosquitoes or almost dying, it was a pretty amazing experience. I heard about my guide from the girl from Holland at my hospital. He works for Ecoexplorers which is owned and operated by Carlos Grande, not to be confused with my GUIDE Carlos, or ME when I go by Carlos down here. (people have a hard time with Ross, and my first name translated is Carlos).

So I met up with Carlos and Carlos Saturday morning at 7:15 to catch a rapido (fast boat) downriver to Santa Maria de Fatima. Despite the mouthful, it's a tiny village of thatched roof, open-air huts spread out sparsely in the jungle next to the Amazon. Carlos is friends with a family there that is always happy to host and cook for tourists, so we based our weekend adventures out of their place.

First was a stroll through the jungle to check out whatever we could find. Mostly trees. My guide had studied a lot of traditional medicine so was full of information about all the plants and their medicinal uses. Pretty cool stuff. I also got to try my hand at playing Tarzan: climbing trees, swinging from vines and the like. Really, just being in the middle of the jungle swinging a machete was pretty neato.



We headed back to the hut for lunch and to escape the midday heat. As afternoon rolled around, we hopped in a motorized canoe and headed upriver to fish. The poles were nothing more than a line tied to the end of a bamboo rod. The fish were all pretty small, but made for good eating later that night. We didn't catch a ton, but managed to pull in a few piranhas and catfish. After fishing, we cruised around until we found some freshwater pink dolphins to watch for a while. I went for a swim off the side of the boat, which was a little unnerving, but totally refreshing. As evening rolled around, we hung out on the Amazon watching the sun set before returning to cook up our catch and spend the night in mosquito-net hammocks.



It strikes me that while all this was really cool, this post is getting kinda long so here's a summary of day 2:
- breakfast of giant snails we found the day before
- hike to a reserve for monkeys
- discover my camera batteries no longer work
- play with monkeys, tucans, anaconda, sloths and prehistoric turtle
- get a monkey tongue up my nose
- try some jungle-brew whiskey/mead
- head back for lunch
- swim in the river, throw local kids off the side of a boat, watch soccer
- climb a tree & get eaten by ants inhabiting the tree
- join a local volleyball game & win 3 soles
- die from overheating, use 3 soles to revive myself with cool beverage
- watch a fierce competition between the local soccer team and a visiting team from another pueblo; rejoice at our victory
- cruise back to Iquitos at dusk watch the jungle fade to black and the lightening flash in the distance
- Praise God for an amazing weekend.

Cooperstown

I'll be living in Cooperstown, New York for the next five years. In case you haven't heard, it's home to the baseball Hall of Fame and approximately 2,000 people in central-ish New York on Lake Otsego, about 4 hours from New York City. More pertinent to this post, it is home to Mary Imogene Bassett Hospital and the Bassett surgery residency program. Additionally, the Mithoefer Center for Rural Surgery is a part of the Bassett program. It is basically an institute geared toward the idea of rural surgery as an entity somewhat separate and unique from mainstream general surgery.

Essentially, this all means that I will be training in a rural town, learning a particularly broad spectrum of surgery and working with other residents who have interest in rural/international surgery.

Learning about my match went down like this. I took a little bit longer lunch break last Thursday, Match Day, to head down to the riverbank and brought my laptop along. I spent some time in prayer and hung out with a local kid who was trying to sell me bracelets before cranking up the computer and learning of my fate. It was a beautiful backdrop for receiving the news and I read the words with some excitement. I ordered some grilled fish, avocado & yucca fries at a restaurant by the river before heading back to work for the evening. That night, I met up with a couple of the residents from the hospital, the two expat girls and one of their boyfriends for some barbecue at The Yellow Rose of Texas, a local restaurant owned by a guy from Texas. It was a great way to celebrate some really great news!

While I had some good options on the West Coast, I can honestly say that none of them have training equivalent to Cooperstown for rural surgery. The skiing won't be quite as good from what I hear, but there are all kinds of amazing recreational opportunities right out the back door. They even have an outdoor hockey rink!

The major downside of living in such a cool place is that it is a ways away from the most important people in my life. In fact, it's about 1-1.5 hours from a large airport. However, I'll be working around 80 hours a week, not leaving a whole lot of time for social engagements. I'm planning to use my time off to head back to Alaska whenever I can though. Overall, I'm pretty darn excited to start residency!!

Iquitos

The two things I consistently heard about Iquitos when I mentioned I was going there next:
1. The girls are really hot there and they will try to put pills in your drink and rob you.
2. The weather is really hot.

So far I've avoided being robbed, but everything else seems pretty accurate.

Iquitos definitely has its own personality, but also has a lot in common with your typical South American city. Instead of taxis, here they have motos, 3 wheel vehicles with a covered seat behind for passengers. It feels more touristy than Huancayo and it's much more common to see gringos walking the streets. The locals are a little more forward here and I made a couple of new friends my first night in town who were supposedly just wanting to practice their English. Who knows. It's also much more common to get hit up by beggars, disabled folks and hungry street kids. I try to help when I can but sometimes there are just too many. No clue how Jesus did it...

Cool random fact: about 5 hours away on the river is the leper colony where Che Guvara hung out in Motorcycle Diaries. I thought about going there, but apparently no one lives there anymore.

(warning, it gets gross here. no, really.)
The hospital here is great. Rounds in the morning are very educational and the cases are fascinating. I can add to my repertoire now dengue, malaria, leptospirosis, TB (with and without HIV) as well as your garden variety parasite infections. I also saw probably the most interesting/grossest case of an acute abdomen and surgery that I've ever seen. This guy came in with peritoneal signs and was taken to the OR for presumed appendicitis. Turns out he had an intestinal perforation in the duodenum... from an ascaris... that they found swimming in his abdominal cavity with a buddy. Apparently it's not unheard of, but quite rare. Also ran into a French fellow who was being seen for leishmaniasis and is here as part of a sanitation project for Belen, the floating shanty town a few blocks from my hotel. He was quite a character and we may run into him again to see what he's working on.

I was reading about leptospirosis on UpToDate today and found that the major study on the topic was actually done here in Iquitos. Random. Speaking of research, the two other white folks at the hospital here are doing some cool projects. One is researching malaria transmission from humans to mosquitoes in hopes of finding a vaccine and the other is researching tropical skin infections. She has a lab set up to do cultures and sensitivies and it was kinda fun to see how all that stuff works. It's usually just something that gets ordered and forgotten until the results come back. It's quite a process though.

Tomorrow is match day. I'm kind of excited needless to say, and have spent some good quality time hanging out with God today in preparation. It's all in His hands!