When things get exciting

So needless to say, things got exciting. Just a quick disclaimer, I'm here on a medical mission and this post will probably be more about the medical stuff, so if you are feint of heart, here is a link to a video of cute puppies to make you feel better. I can't vouch for the video, however, as Youtube is blocked on the Mbingo internet.

Just a little casual musing first. Why is it that we fixate on our failures and not our successes? Is it because we really want to better ourselves and think that by working through lapses in judgment we can avoid them in the future? Do we feel the need to punish ourselves even when no one else condemns our actions? Maybe our pride demands that we expect more from ourselves than we are capable of and failure is an affront to inflated self-esteem. Still trying to understand this reaction...

That said, I have had a lot of successes here. My first patient is looking great and smiles and waves every time he sees me. That's an emotional boost! I feel like I've connected pretty well with the residents and have been able to do some teaching and some learning from them on cases that I'm unfamiliar with. I've taken on some surgeries that I've only read about, with the help of some very competent, experienced residents and some friends from home weighing in by text message. I'm not sure how it will turn out, but on Sunday I operated on a 2 kg 5 day old baby whose intestine failed to develop correctly leaving it in discontinuity. After discussion with the residents here, a panicked text to a friend (who just happens to be a stellar pediatric surgeon) and a consultation with my lovely wife (who knows WAY more about turning sick babies into healthy babies than I do), we charged ahead and managed to get through the repair feeling pretty good about things.

Yay! Fireworks! Cigars! Champagne! (except there is a ban on tobacco and alcohol on the hospital grounds) so... Orange soda! Granola bars!!

And then the next day, I was signed up to take a kidney out of a 2 year old for cancer and the cancer turned out to be too advanced to remove. The worst part is, I didn't realize it until we were most of the way through the operation.

That kind of stuff happens in medicine, but it happens a lot less when you have good imaging studies and specialists and seemingly endless resources. A simple CT scan would have shown us the tumor was too advanced to operate, but all I could think of was why I wasn't more careful early in the surgery to determine if proceeding was a good idea. I'm not sure, but I'd like to think I could have figured that out much sooner than I did and saved the child unnecessary trauma. I feel like after an experience like that you should get a time out and everything should stop until you're ready to forge ahead, but that was about 4-5 surgeries ago and somehow you just keep going.

I wonder sometimes how hard it would be to raise a bunch of money for a noble cause. I really like to think that I could get up on a podium somewhere and tell a really inspiring story and people would be so excited that they would just start donating like crazy to some charitable cause. There's a family doc here who is a really great guy and some one who doesn't sit on an idea long before taking action. When we talk about things that we are worried about, he is always the first to say, "Well let's just pray about that right now!" and proceeds to do so. I was talking about this case with him and he just suggested that we raise the $125k that the hospital would need to buy a CT scanner. I love that idea. They already have a room under construction and a guy training to be a radiologist and there would be immeasurable good done here by the addition of CT capabilities.

To illustrate and tell one more medical story, a guy with a head injury came in over the weekend and rather than getting a CT scan, which we would normally do, to guide treatment, we took a hand drill and drilled a hole in in his skull to see if there was any internal bleeding causing a problem. There wasn't. The patient didn't have much of a chance even at initial presentation, but it sure would have been better to know what we were getting in to than going in blind. This guy was probably more the rule than the exception unfortunately. This place sees a ton of trauma and a CT scanner would likely be working 24/7 assuming it didn't break down. I'd love to tell you where to donate to help this place get one, but I haven't been able to figure that out. Hopefully I will before I leave.

I feel like the tone of this post was much darker than I intended, but as I said, I think we tend to focus on our failures more than our successes. I'm having a great time here and will be leaving in a few short days. It has been awesome to reclaim that feeling of inspiration to get outside my comfort zone to try to do some good in the world. Being here is making me a better person, a better surgeon and a better follower of Christ and I'm incredibly grateful to be here.

Cameroon

Hey, so I think it has been several years since this blog saw the light of day, but it's also been a while since I've been overseas for any kind of humanitarian purpose, so what the heck, might as well do a little catching up. No promises about being particularly entertaining or insightful. I'm planning to use this more as a person reflection/travel log.

I had a pretty uneventful trip. Typical trans-Atlantic stuff like watching movies until my eyes were bleeding and I developed a pressure sore or two and enjoying the free adult beverage service. I slept most of the way between Paris and Yaounde. Arriving in Cameroon brought two considerable reliefs, #1 seeing my bags make their way down the conveyor amidst a huge throng of travelers cramming themselves up against the belt. (Why do people feel like they need to stand next to the baggage claim belt? Doesn't it make more sense for everyone to step back a couple paces and just step forward to grab your bags???) And #2 seeing a smiling face with a white "CBC" sign. I've always thought it would be cool to be one of the people that had a sign person waiting for them at the airport. And trust me, the actual experience lives up to the hype. (CBC = Cameroon Baptist Convention, an organization that runs several hospitals and clinics in Cameroon)

My sign-holder was a guy named Fon (like phone) Bangaman and after gathering the other two visiting docs from the airport, he whisked us away to a pretty ghetto hotel, a restless nights sleep and then an 8 hour drive with questionable passing methods and even more questionable road conditions. We survived and the spent a few days recovering from the whole ordeal. Day two (Saturday) one of the longtime docs here took us on a 7 mile hike around the property to show us some of the current and planned infrastructure while getting a great view of the surrounding mountains and countryside.

A quick recap of some of the highlights of the past few days:
-My first surgery here was an ex lap for a bowel perforation in a 13 year old. Apparently typhoid fever is still out there and can cause spontaneous holes in your small intestine. Caution advised.
-Cameroon church was a lot like American church with an accent. I was kind of hoping for some sweet African drum sessions, but alas, Western culture has come in like a plague.
-Been having a great time hanging out with Ethan Helm and his fam. He is a pediatrician and his wife is a family doc and they are here for 2 years. They gave me a shopping list before I left Alaska and so we got to have chocolate frosting on their 3 year old's birthday cake the other night. I could write a whole blog about these guys. Maybe I will. Fortunately, they did already here.
-The surgeons and residents here have been really welcoming and wonderful. I've really enjoyed working with them and have been amazed at their level of skill, breadth of knowledge and devotion to God. This is a pretty awesome place.
-I've been recycling some of the lectures I put together in residency for teaching sessions with the residents here.
-All of my meals have been provided by an extension of the hospital that houses and feeds short term missionaries and docs. Food has been great and meal time is a good time to catch up with the other short-termers and compare notes on our experiences.

I'm on call tonight so we'll see what the night brings! The residents take care of an incredible amount on their own but you never know when things could get exciting...

Loma de Luz

I'd heard of this hospital on the northern coast of Honduras a few years ago and had kind of tucked the connection into the back of my mind, so when I started planning a trip to Central America again, the memory surfaced and thus I found myself cramming into a 3-wheeled moto-taxi on a dirt road to the middle of nowhere.  I had woken up that morning on the island of Roatan, taken the ferry to La Ceiba and the bus to Jutiapa before finding transportation for my final leg.

I arrived at the hospital and after the initial deliberations and niceties met a middle-aged guy in jeans and a T shirt who introduced himself as Dr. McKenney.  He and his wife, a family practice doc, were in the middle of their persistent work of organizing, planning, arranging and coordinating the work that is Loma de Luz and its many offshoots.  Graciously, he took some time to show me around in the midst of all that and incidentally set and casted a patient's arm. 

They have a pretty incredible story of which I only heard a small part, but essentially they were stymied in their efforts to become longterm missionary doctors for any organization so spent 10 years developing contacts and organizations both in the U.S. and Honduras to build a new hospital.  The Honduran government steered them to a location where the mountains meet the ocean that years prior, Dr. McKenney had seen on a map and dreamed of going.  His dream coincided with the need in Honduras and Loma de Luz was born.

The actual facility defies the conventional model of a Latin American hospital in that it provides a multitude of services in the same place, but extends to provide a foster home for children, educational facilities, a hub for communications, housing for visiting missionaries and many other services.  Additionally, a majority of patients are able to hear the Gospel, not in a compulsory fashion, but in a "this is who we are and why we do what we do" fashion.  As a side note, Dr. McKenney has also been working on developing his own biodiesel from African oil palm which has been planted liberally around the grounds in an attempt to get off the grid a little more. 

For having only spent a couple hours there, the impact and amount of information I gained was huge.  My head was reeling a little bit as I traced the route back to La Ceiba and boarded a bus for Teguchigalpa.  I was incredibly grateful for the example and incredible dedication of the McKenneys and was really challenged to take seriously this work I have been called to.

Honduras to Nicaragua

I started getting the itch to travel this last year. Not just to go somewhere, but to be on the ground, seeing life as it is elsewhere, smelling the air, tasting the flavors and walking the streets. I hadn't been out of the country since residency started but didn't really have a great idea of a place to go or a time. So I conferred with some friends and picked a week in late April to head off... somewhere. My friends couldn't go, but I came to find out that my sister had planned a vacation that same week for Nicaragua and thus my destination was set.

I'd had in the back of my mind for a while a trip to Honduras to visit a hospital on the northern coast started by a Christian surgeon and his family practice doctor wife and thought this would be the perfect chance to swing by. So after a long week of late hours at the hospital (which I have come to accept without such opposition as before), I took an early morning flight out of Albany.

I had planned to spend the night in San Pedro Sula, but after talking to some folks on the plane, I figured out that the northern coastal city of La Ceiba had a litte more to offer, including a ferry ride out to an island named Roatan, known for scuba diving. Walking the streets of Honduras put me on edge moreso than other Latin American countries I'd visited. Maybe it was the swath of strangers warning me about the dangers of being robbed at machete-point or maybe just the looks that I got walking around, but either way, I retired early and didn't seek out the night life during my time there. So after catching a taxi and bus to La Ceiba and spending the night in a cheap hostel, I found myself on a rough ferry ride out to Roatan.

The cultural scourge that is Facebook served me well by connecting me with a classmate from medical school, Camille, who happened to be in Roatan at the same time. I was hoping to meet up with her there, but while walking the streets shortly after my arrival, I ran into some one else first. A girl who had walked by on the street caught my eye and looked a litte too familiar for me to not say something. So when I said her name and she turned around, I was surprised, but expectantly so to see Scarlet, another friend and classmate from medical school, who I'd visited in Boston earlier that year.

I spent the next few hours catching up with her and then wandering around for a while and hiking down the beach to the neighboring town where I ran into Camille and her family. I ended up hanging out with them all night and was treated to dinner, drinks, a herbit crab race on the beach and an evening fire-dancing performance. A fantastic day!

Waking early in the morning and catching the ferry back to the mainland, I traveled all day and spent the night in a sketchy-looking hotel in Tegucigalpa, roommates with a big black guy named Robert, a Nicaraguan working in Grand Cayman and taking the same long bus ride as me from the northern coast of Honduras to Managua, Nicaragua over two days. The actual bus ride was fairly uneventful and found me rolling into Managua in late morning. Two side notes, 1) Tegucigalpa (or "Tegus") is not a very pleasant place to be, particularly on the street at 11p.m. and 2) If you're going to be on the street at 11p.m. in Tegus, having a big, black friend is quite reassuring.

Part of the day's travels included a quick jaunt out to Loma de Luz, an incredible place worthy of a dedicated telling...

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!

Change of plans

The thing I hate about putting off blogging is that I can't type everything that I want to. Lots of cool stuff this past week but the most interesting and pressing is this:

I have left Huancayo and just bought my plane ticket for Iquitos, a port on the Amazon River in the middle of the jungle.

Yeah, I'm pretty stoked, but it was hard to leave. It's always hard to leave. I met some really great folks in Huancayo including my expat crowd, the doctors and interns, my host family and newly met friends that I never got to know well enough.

This week in the hospital I finally got to see a few surgeries for hydatid cysts which was pretty interesting. One was in a kid of about 11 years old who had two hard-to-access liver cysts. Pretty interesting surgery, but straightforward. I got to do a little more suturing this week on skin, but other than that, it was a pretty typical week of watching surgeries, attending rounds in the mornings and hanging out in the ER in my downtime.

Outside the hospital this week, I took off to play soccer with the surgeons at a doctors' pavilion for recreation. I played goalie and had a few nice saves, but let in a lot of goals too. They ended up hanging out for hours afterward passing around bottle after bottle of Cusquena and telling stories. Not my favorite post-game activity, but later I was invited to a doctor's house for a fantastic meal.

I also ended up over at the expat house one night for crepes courtesy of our French-English friend and met up with my friend from the disco a few nights this week for late-night snacks and conversation. Dr. Montano gave me a great send-off by inviting me over to listen to music and drink some wine. He presented me with a surgery manual in English that he had from training in Cuba... quite a gift!

My host family and I went out for dinner at La Lena (there are about a million of these, but the one on Brena is the best) where I had one more amazing steak before heading out. The next day they prepared an awesome lunch of basically fajita steak, onions and tomatoes and homemade chocolate pudding for dessert!

I met up with Joseph the Peruvian with my backpacks in tow to head out to obtain passage to Lima. I ended up booking with a car instead of a bus because the bus was really expensive during the day and driving in a car is much faster (supposedly) but one broken fan belt later found me sitting on the side of the road between Huancayo and Lima hanging out with my newfound friends, the other passengers in the car, one of whom was a policeman from Lima. Good times.

We finally arrived and I met up with Mario and a big group of his amigas to close the night out with karaoke.

Redeeming a bad Monday (2/2)

Fresh out of the hospital after an unspeakably frustrating morning, I took a long walk home to chill out a little. I spent some time relaxing at the house before calling up a friend to meet up in the park (the Jesus-lovin' gal I met at the discoteca). There was a crowd at the park watching a heated volleyball match and when I asked, it was a team of "maricones" that was dominating. Now there are about a billion words for homosexual in Peru, but maricon (merry-CONE) is the most widely accepted.

My friend and I went for a walk and talked for a while at a juice stand where they basically blend up whatever fresh fruit you want and dump it in a glass. Delish. She had some wise things to say that helped redirect my angst and we discussed our life goals and stuff. Good times. She had to cruise to class that evening and I headed back to the park to try my hand at volleyball.

I watched the conclusion of a match where the maricones again kicked some major butt. It seemed that the winner of the match kept the court and took on challengers. So I hopped down onto the court to see if I could join the next group of challengers. However, as soon as I stepped up, the whole crowd started cheering. Apparently, gringos don't show up to play volleyball a whole lot. As our team slowly formed, one of the reigning champs told me to join their team, as they were one down. If I thought the cheering was loud when I walked on, it was doubled when I stepped onto the other side of the court.

We ended up playing a pretty close match and some really good volleyball. Man, those guys can play. There were definitely a few pretty hilarious moments like when one guy set the ball for me to hit and simultaneously called out "Mi amor!" I'm used to getting teased about the girls here liking me, so it really wasn't that much different and everyone was just out to have fun and joke around. We ended up winning, and apparently there was some money on the game because I came away 1 sol richer. I wasn't a standout player and made my share of mistakes, but also got a few nice spikes in. They invited me back at least...

Afterward I met up with my gringo crew at a pizza joint downtown for some good times and okay pizza. My friend finished her classes and took me to a bar with live Peruvian music and colchitas (kind of like spiced rum) for a nightcap before I tucked in for the night.

It was a long day and the stark contrast between my morning and my afternoon still surprises me a bit, but I'm thankful that the pain of my lesson in humility from that morning was far outshone by the richness and the fullness of engaging in the lives of the beautiful diversity of people that God has made.

Lessons in Humility strike again (1/2)

Ever have those days when you know what you're supposed to learn from the hard things you're facing, but you just don't care and you want it to be made right??

Welcome to Monday. Having been here for 3 weeks, I assumed I would be given a bit more liberty in the OR and much to my delight, I was offered the opportunity to assist on thoracic cases... on Monday.

Up to this point, I've gotten to assist only a couple times, with the majority of my time being spent watching and leaning over the surgeon to help retract. Reminiscent of shadowing a physician during my 1st year of med school. In contrast, during my surgery rotations this year, I've done a below-the-knee amputation myself and assisted on neck dissections, opening the chest for heart surgery and multiple thoracic surgeries, not to mention doing a fair amount suturing upon closure for most cases. Coming to Peru, I was hoping to get even more hands-on experience while learning about endemic diseases.

So I showed up, on Monday, ready to get my hands a little dirty, but when I walked into the OR, the patient wasn't in the room. When I check again, they still were there... 30 minutes... 45 minutes... an hour... hour and a half and no patient. In fact, the surgeon that I'd met and was planning to operate with was nowhere to be seen either. I finally got up and sought out the anesthesiologists. They essentially told me that all of the thoracic cases were canceled for the day. Upon further inquiry, they informed me that thoracic cases are complex and they should have two real surgeons operating for all of them.

I wanted to scream in their faces that I have assisted on thoracic cases at the Oregon Health Sciences University Hospital and if I was good enough there, I should be good enough in Huancayo, Peru.

I managed to keep cool for the most part, but when one of the interns graciously offered to let me watch another laparoscopic gallbladder surgery, I should have said thank you and scrubbed for the surgery. But I told him, instead, that at this point, I don't have the humility to stay and watch anymore. He understood the situation. I left.

In speaking with my attending about the situation later, he explained that allowing me to assist is not necessarily illegal, but is borderline, and he believes that there was some concern about litigation. Still. It stung.

Fin de semana #4 - R&R vs R&B

I had planned to stay in Huancayo anyway, but when fever struck Thursday night, thoughts of fleeing the city for the weekend vanished. I was bummed to call in sick on Friday because a pancreas specialist was visiting for the weekend, events to include a dinner on Friday, rounds on Saturday and some teaching on the subject. So instead, I spent Friday sleeping/watching movies/sleeping and trying to pretend like I wasn't there. My host family finally discovered me late in the day and did their best to coddle me, which I resisted only half-heartedly.

Saturday saw much improvement and having reassured myself that I didn't have anything scary like TB or malaria, I headed over to my attending's house for lunch... or so I thought. As it turns out, he's somewhat of a gourmet and I arrived to find pork glazed in honey smoking in a homemade contraption in the back yard. His house is beautiful, with a garden in front and back with all kinds of interesting, edible plants that I can't begin to remember the names of.

However, for him, being at home on Saturday does not necessarily mean not working. Across his back lawn is the back entrance to a clinic that he shares with his wife, a dermatologist. Throughout the afternoon, patients would drop by for appointments or check-ups and he would duck out for a few minutes. Later in the day, he told me to come with him and we wound up in a private clinic doing a hernia operation on Saturday afternoon.

As I was watching, it gave me room for pause. My ideal career consists of working really hard some times and playing really hard at others, hopefully helping people along the way. His life is nigh consumed by surgery and patients, even in his free time. When I questioned how he manages this, he replied that he does what is necessary to support his family both here and in Cuba. It was quite sobering.

Saturday evening, I headed over to a gathering of a bunch of expats at the house of my friends from the jungle trip. It was a great night of hanging out, drinking wine (Romanian pinot?), eating lasagna made by my British rockstar friend (to be fair, he hasn't made it yet, but his music is fantastic) and hearing stories from all over the world. We had folks from France, Bermuda, England, Ireland, the U.S. and Peru all converging over dinner. Excellent.

Nighttime found us trying out a new discoteca, La Noche, which was a flop so we moved on to familiar haunts, a discoteca they frequent frequently and I'd been to once, Taj Mahal. In addition to a great night of dancing, later on, I was recruited to meet a couple of Peruvian gals with my British buddy. As is prone to happen, the girl I danced with asked why I was single, but when I started talking about my faith, instead of a blank stare, her eyes lit up. We ended up talking quite a bit and we have pretty similar stories and love for God.

Not that such coincidences are unheard of, but it is rare to meet some one in Peru that loves God but can still go out dancing and have a glass of wine or two. Anyway, it was super great to meet some one had a genuine love for God and was excited to talk about it! God must have known that my Monday was going to be really frustrating and I'd need some encouragement. More on that later.

Sunday I slept in and then headed back over to Dr. Montano's house for a lesson in making ceviche, a Peruvian delicacy. We hit up the market to buy supplies and that was an experience itself. He had fewer patients on Sunday and I slipped out a little early to spend time with the expat crowd. They'd had a barbeque that was winding down when I got there, but the music was winding up. I was treated to live performances by my British friend, the gal from Bermuda who sings some mean blues without accompaniment and the local on guitar and wooden flute, which is in a lot of Peruvian music.

I winded down the night with a walk to the central plaza. Snagged a burger and fries and sat down to eat and think and pray. Got accosted by a group of Peruvian gals on vacation who all wanted pictures with a gringo. Back to prayer & meditation. Reenergized. Back to the casa for a conference call with my college roommates over Skype to finish off the night and me.

The Daily Grind

The alarm clock is set for 7 a.m. (which means I roll out of bed at about 7:20) and breakfast is waiting downstairs. The initial offerings included fruit, eggs and avocado, but the family I'm staying with has since realized that I really only eat a piece of bread and drink a cup of coffee (instant coffee, sugar, milk & hot water). If I'm feeling ravenous, I'll stack on some jelly or a piece of cheese. I'm out the door at 7:45 and walk less than a block to the main road through Tambo. Huancayo proper is actually a bit to the south of my place. It usually takes a couple minutes to spot a legit taxi looking for a fare. The price to the hospital is 3 soles, which equates to about a dollar.

Five minutes later I'm at the entrance to the hospital, greeting the security guards at the gate, walking through the courtyard and I head to my daily work. Since obtaining my white coat from Dr. Montano, none of the guards have really questioned my right to be there and give me confused looks when they ask my last name, but let me by.

Mondays, Wednesdays and Fridays I'm in the OR all day with the general surgeons. Occasionally I'll check out other surgeries. This week I stepped in on an emergency GYN surgery for a ruptured ectopic pregnancy (lots of internal bleeding) and a revision of a nasty tibia fracture. I don't do anything, just watch. Wednesdays I scrub in with the pediatric surgeons and usually get to help out a bit. This week we removed a 10 pound ovarian tumor from a 13 year old. It was ugly.

I suppose it was the arrogant American in me that assumed I would walk in and get to operate or have a pretty active role in the OR, but there are usually two surgeons on all general surgeries and they work 12 hour days doing nothing but operating. I share 2nd assist duties with the interns here. On simple surgeries, I sometimes first assist and actually got to head up removing a fatty tumor from a guy this week. It has tested my patience to sit and watch surgeries that I've seen a lot of already, but I will be there soon enough.

Tuesdays and Thursdays I generally tag along for morning rounds with the surgeon of the day and the intern covering the surgery floor. After rounds I help with dressing changes, wound care and sometimes head down to the ER to hang out with a doc down there. Dr. Carlos is a medicine doc that is pretty proficient in English and enjoys the chance to practice, so I've been hanging out with him in the ER when he's on. I actually learn quite a bit of medical Spanish from him as well.

I'm usually out the door before 5 on non-OR days and today I came home for a nap, which wiped me out for the rest of the day. I walked downtown to see if I could catch a movie at the mall, but the one I wanted to see was in Spanish rather than in English with subtitles. Sometimes I just need a break from stumbling through Spanish.

So instead, I ate dinner at the mall food court and then headed to the central plaza/park and just hung out. This may sound kinda corny, but tonight was kind of a date with God. I haven't been doing so hot on spending time with Him lately and tonight was a great chance to just relax and enjoy the presence of my Creator.

This weekend is looking like it will be full even though I'm probably staying in Huancayo. I'm okay with that, especially considering that I have a potential grand adventure in the works...

Fin de semana #3 - Welcome to the Jungle

La Merced was the destination. The group consisted of 3 girls I'd run into in a restaurant while out with the doctory type, a Huancayino and an English rockstar. The girls were from Maryland, N. Carolina and France/England and are here volunteering at an orphanage. After a quiet Friday night at home for me, we met up at the bus terminal on Saturday a.m. to commence our journey.

The rest of the crew was wiped out from dancing until 4:30 in the morning, but somehow managed to rally for an 8 a.m. bus ride. I was so proud. So we talked briefly before most of the crew passed out on the bus. I enjoyed the beautiful scenery between Huancayo and La Merced and tried to sleep when the turns got a little too twisty.



Upon arrival in La Merced, we snacked (a popular pastime with this group), they slept, I visited a local hospital and we embarked on a beautiful hike through the jungle to a waterfall. We made it back that night in time to eat and experience a small amount of the city life before tucking in for the night.



We arranged for a guided tour on Sunday, which I will admit I was not a huge fan of, but I was following the crowd. It turned out pretty great. We learned about local history, agriculture, native groups and such. We even visited an "authentic native village" where we were greeted with traditional clothing, a story, dancing and exotic animals. Afterward, we were expected to buy souvenirs and stuff, but I didn't. I did pay 50 cents to have my picture taken with an exotic rodent (pacarana) eating an ice cream though.



Finally, we got down to business and headed way out of town to hike up to another waterfall that was pretty spectacular. We went swimming despite the coolish temperatures and I got a great massage from the cascading water. I also managed to take a fall off a boulder that I was climbing, but our guide, Jesus (hey-SOOSE), was there to catch me and I wasn't hurt a bit. Anyone care to comment on this irony???



There was tons more that happened over the weekend, but it was little stuff, like getting yelled at about nutritional supplements on the bus, riding on the back of a moto taxi, trying to make animal-shaped balloons in the pub, countless jokes with new friends about American vs British culture, eating giant rodents, finding obscure bands in common with people from across the pond, driving through a river on a cliff and hoping the bus wouldn't slip and planning our next escapade. Believe me, it's in the works, and it very well may involve snacking.

Work, work

After a weekend full of excitement, it's been a busy week in the hospital. I set a new record for number of surgeries in one day one Monday with 8, then subsequently one-upped myself on Wednesday with 9. These were no more than 12 hour shifts too, I might add.

It's a little different here than the states, needless to say, and I've found myself a little frustrated with some of the differences and a little relieved at some of the others. I've come across some interesting cases here including a fluke inhabiting the bile duct, a set of triplets today, a horrible necrotic reaction to an NSAID injection and a horrible case of necrotizing fasciitis following a hematoma caused by a fairly innocuous fall against a table. (my apologies to the non-medical folks)

I was expecting to be doing a little more hands-on work, but there are a good number of other students and residents around in this hospital. Occasionally I'll get to first-assist in a surgery, but there's a lot of watching, cutting sutures and retracting while some one else is doing the real work. All in good time I suppose. The other students are really nice and pleasant to work with. I usually take a little time to help them with dressing changes on the wards, but don't really have a whole lot to offer.

I spent Wednesday and Thursday with the pediatric surgeon and saw a few good cases. The most common stuff here in kids includes hernias, ankyloglossia, cryptorchidism and hydatid cysts from parasites. We operated on the former three and saw the latter a few times as a consult. It was a nice change of pace seeing kids in clinic. The pediatric surgeon gets teased for being not only a surgeon who operates on children, but a surgeon close to the size of his patients, but he takes it well and is overall a really great guy. One of the most important qualities for an attending is a willingness to teach and he excels at this.

I met up with an American kid last night whom I had met last weekend at the discoteca. I didn't know much about him, but it turns out he's a seriously committed Christian but has a much different path than mine. He had a pretty great story of coming to Christ and encouraged me in a lot of ways. We share a lot of similar beliefs and both have a desire/calling to do our small part to bring a little more love into the world, particularly the developing world. It was kind of funny because earlier in the day I had spoken with a good friend who mentioned he was praying that I would find community.

I'm currently waiting for a call from a group of expats who are here volunteering at an orphanage. We're planning to probably go out dancing tonight and then head out to the jungle town of San Ramon for the weekend. More on the later.

Fin de semana #2 - Huancayo & Inginio

After 4 days back at work, it was time for a little R&R. My friend Mario came in from Lima (as a reminder, a Peruvian neurologist I met in Seattle) and we decided to hit the town. We met up with two Peruvian gals, the daughter of my landlord and her cousin and commenced with the revelry. This included karaoke (I bust out a mean Bon Jovi), live music and dancing until the wee hours of the morning. Come to find out, the cousin is actually a dance instructor! Major bonus... not to mention that she was "Miss Huancayo" for two years running. Some ridiculous luck I have.

We managed to get up in time to finish breakfast by noon at Mario's family's restaurant a few miles from my place. Restaurant may be a slight misnomer as it's more of an outdoor cafe, but the food was great if not your typical breakfast: sopa verde and cau cau (a kind of potato soup and a dish with cow stomach, potatoes and rice). That afternoon we had a nice walk around his old neighborhood, made friends with a little girl who showed us how to get past the gate down the river and generally goofed around along the Rio Mantaro. Later that day I fell asleep on the riverbank of another river close to town where people were bringing in a huge carrot harvest. We closed out Saturday by heading to La Cabana for dinner and internet.

Sunday was amazing. Mario and I had heard about a good place to visit in the mountains on Saturday from a guy by the river, so we headed out to see if we could find "Arco Iris." We took a shared-ride taxi out to Juaja (hoo-huh) and then hired a taxi to take us to a little more remote area. We ended up outside Inginio, a fairly touristy spot for expats and locals alike. Green mountains, a clear stream and lots of parks tucked in the valley. We arrived next to a park with a family playing volleyball and asked if we could join. They ended up inviting us for lunch too: pan-fried truche (true-cha) with red chili fired in a pan over a camp fire. IT WAS DELICIOUS. Supposedly truche is a small, imported salmon, but whatever it is, it was amazing. The family was celebrating one of the girls' birthdays, so Mario and I made sure to sing Happy Birthday in English. Her little brother was hilarious, a 3 year old named "Peidrito." We also took a few moments for a hike up a valley before being turned back by the approaching rain.

Instead of paying our way back to Huancayo, we snagged a ride with the family and treated them to ice cream from a local creamery (fresh milk!) on the way home. Back in Huancayo, we got caught in a "chaperon," a fierce, but brief, downpour. As it broke, we left our shelter on the side of the street and passed through the Sunday market. I snagged an alpaca sweater for 10 bucks... not bad, not bad.

We rounded out the day with a church service with Mario's mom followed by another trip to La Cabana for good food, wine and an incredibly uplifting conversation with Mario's mom. She exudes a sense of warmth and joy and was able to speak some really powerful truth to me about trusting in God and how ridiculous it is to doubt Him.

After this weekend, I can't say a word to disagree with her.

A lost stethoscope saves the day!

Not that today was bad, it was pretty enjoyable actually, but there were no surgeries scheduled and I spent most of the day seeing post-op patients with one of the other surgeons and hanging out with people... not a lot going on. I was about to head out early for the day when I realized I had left my stethoscope in the locker room the day before. I went to the OR locker room, and it was nowhere to be seen.

Now losing a stethoscope shouldn't be that big a deal, except that mine was given to me the summer before med school by my cousin who is a pediatrician and taught me during my 3rd year. It has sentimental value. And it's a nice stethoscope.

So I inquired to multiple people including surgeons, cleaners and nurses and finally they told me to talk to the chief of surgery. Within a minute or two, he had one of the cleaners bring it from the lost and found, a huge relief. I thanked the surgeon who referred me to the chief and as we were talking, he asked if I was busy. Well, not really, no. I was about to go home actually. He invited me into watch a pediatric surgery and I hastily accepted.

It was a 13 year old girl with fluid in her chest from tuberculosis. I ended up as the first assistant rather than a spectator and actually got to help quite a bit. They even let me help close. I tried pretty hard to skin the skin closure done well as this girl will have a pretty sizable scar on her back/side for the rest of her life. It was pretty sad to see someone so young so sick, but the nice thing about kids is they get better pretty fast.

On another note, I was praying about residency last night, wanting to make the best choice and was asking for wisdom. The idea to read Jeremiah 27, which I don't really know much about, popped into my head and so I did. It discusses the Israelites being sent away from their home, the places they loved and the land they were connected to, to live in Babylon. For them, it was a strange foreign city and they had set their hope on an imminent return. However, Jeremiah told them to invest in that city and work for its good, that their fates were tied to the city they were sent to and that they could prosper there, even away from home, if they chose.

I thought it a pretty awesome answer to prayer. Not that I'm 100% sure of where I'll end up (I think I know), but that God is working to bless wherever I go for residency and I can choose to be a part of that.