Sunday, June 24, 2012

A Day in the Life...

I know I promised to write more, and here I am with mostly regular internet access and I am doing worse at writing than I did when I had only weekly access!  Sorry!  I'll make up for it with two posts this time.

Let me begin by saying that Siem Reap (the city in which popular tourist destination Angkor Wat is located) has a totally different atmosphere both from the villages where I have worked in the past and from Phnom Penh, Cambodia's capital and largest city.  It is very Western because of all the tourists, plus it is a popular landing site for expats and a central place for NGOs.  It is chock-full of restaurants selling Khmer and Western food (meaning you see traditional dishes like Amok, things like morning glory in oyster sauce and fried noodles, on menus alongside things like pizza and cheese burgers, plus you may or may not see Thai, Korean, Indian, or Chinese food as well, or even some sketchy Mexican and Khmer places), and I can't walk more than 50 feet without someone calling out, hello!  Tuk-tuk miss? (tuk-tuks are motor bikes attached to fancier carts), and when I politely decline, asking tomorrow?  See Angkor Wat?  It makes me smile, really.  The upside is that many speak a passable degree of English, so I could do things like borrow a pen from the waitstaff at the restaurant I have been frequenting, and manage to be understood.  I do miss the simplicity of being in the villages though, and the constant interaction with fascinated villagers.  I miss the vieilles and their toothless smiles, the children calling out, hello!, being surrounded by Khmer and forced to practice.

A day starts for me around 6, which is when my body has, without exception, decided it will wake up.  (This is now two and a half weeks in, and still matter when I go to bed.)  Recently at least, I can almost go back to sleep by the time I get up, at 7.  I get ready and come downstairs for breakfast at the guesthouse.  My current favorite dishes are banana-chocolate pancakes (with banana in the pancake and chocolate on top) and bread with vegetables and cheese (because I have a penchant for melted cheese and the mini baguettes are quite toasty!).  I get to the hospital around 8:30, usually walking with the one or two premedical students who are also doing this program, and my translator (who is a nearly finished Khmer medical student) meets us there.  Rounds start whenever the doctors arrive from their morning meeting (which I surmise is a bit like Grand Rounds where a case or disease is discussed, but I am not entirely sure).  Rounds may or may not go quickly, depending on the complexity of the cases, how many operations are scheduled for the morning, and whether one or both of the surgeons is present.  One surgeon is a younger, quieter man, though when I worked with him for most of a morning, I was surprised at how much English he spoke and how much he too seemed to enjoy teaching me.  The other is far more effusive--he has a constant twinkle in his eye and loves to laugh and joke with the nurses and patients.  He is the one with whom I work the most frequently and he really seems to love his work.  He is also a great teacher, prone to asking "pimping" (basically, the questions the attendings love to ask students) questions in French, English, or Khmer depending on his mood and the complexity of the question.  He also loves to look at an interesting patient and tell my translator and I to discuss, leading us on a brief history/physical and discussion between us as to what labs to order.  Sometimes I have to stop myself and remember an ANA or dengue titer is not available for the vast majority of Cambodian citizens.  After rounds, we'll go to the OR (I'll post about this soon) and watch as many surgeries as the morning will have, then we will sit outside for a bit and discuss a tropical disease like dengue, typhoid, or for tomorrow, leptospirosis. 

The afternoons are usually quiet here.  The doctors need to work in private clinic as well as public to make sufficient money (or more than sufficient money...) for their families, so the hospital pretty much goes silent in the afternoon (the moral of the story is if you're a patient, you do NOT want to have a crisis in the afternoon, where there are primarily nurses around and there is also a doctor on call).  The doctors go to their respective clinics after lunch.  Most days, I come back, have lunch, write, sometimes I talk with people, sometimes read.  Lately, the animated surgeon has been telling me if he or someone else is on call and has an afternoon surgery, and I'll go and watch.  In the evenings, usually I meet with the two premedical students and we get dinner.  Our favorite place is Father's Restaurant, whose prices don't exceed $3.50 or $4 for anything on the menu.  They have lovely Khmer food (tonight I had a soup like egg drop soup), coconut water from a coconut, excellent fruit shakes, and so much more, plus the staff is really sweet--and they recognize us by now :) 

I really am having a good experience!  I don't always feel I am doing a lot of good, but I am learning a LOT about medicine in Cambodia and learning how things are done, getting ready for my own rotations at Georgetown that begin in just two weeks....

Thanks for listening :)  I will try and give you a glimpse into surgery in the very near future!

Tuesday, June 5, 2012

Second Year of Medical School

Second year of medical school....rumored by some to be the most intense year of medical school and indisputably a challenging, busy year.  That perhaps explains, while not entirely excusing, my lengthy blog silence.  Still, I have to say--I (mostly) loved second year, and I am tremendously excited to begin clinicals in July. 

Second year falls in a steady rhythm: four weeks of consistent class and studying with the ability to take a night off here and there, to visit friends in the area, followed by two weeks of class and more intense studying and slightly rising blood pressure, and finally, two weeks of nine-plus hour study days and four exams, where the light of day is barely seen (with a few pauses when sanity is needed).  Then, the cycle begins again.  Really, I prefer it to the first year schedule of exams every two weeks.  Sure, there are about three weeks that are way more insane than any time in first year, but the stress ebbs and flows.  There is recovery time, less guilt when an afternoon is taken off for ice cream or a walk or to hang out with friends.  If first year told you everything about how the body works and where all its parts are located, second year told you everything that could go wrong and how to treat it.  The analogy of flinging mud at walls hoping some sticks is fairly accurate, but I did love the material.  It felt much more clinically relevant and tangible.  I do remember some of it too; for instance, I can probably tell you how to treat hypertension, recognize bipolar disorder, take a much better health history, and tell you what to expect with heart failure.  Most pharmacology no longer sounds like a foreign language, and Microsoft Word has even learned how to speak it :) 

What are some of the lessons of second year?

(1) Boards are omnipresent and awful.  Sorry to begin the list with a downer, but anyone who has been to medical school knows that Step 1 of the medical boards is kind of an obsession throughout second year.  Professors are known to indicate parts of lectures that are "often on the boards."  Bits of information are added specifically for that purpose.  Talk scatters about "q-banks" (series of questions and explanations), "First Aid" (tells you almost everything you need to know for boards), "DIT" (one of the online prep classes).  Having studied for them since October and taken them nearly two weeks ago now, I can say it is seven hours of brain drain for which I paid nearly $1200, but finishing is definitely an accomplishment, my span of knowledge is more, and I just keep my fingers crossed for a good score.

(2) Many patients really do respect you as a physician.  During fourth quarter physical diagnosis, which took me and a partner to a hospital in the area, we had the wife of a patient shoo a visitor away for a few minutes because,  "the doctors are here right now."  Even with the short white coats and stethoscopes and reflex hammers that feel much more awkward than natural in our hands, with a mouth that stammers out history questions and fingers that furiously scribble answers for fear of forgetting anything, minds that search desperately to remember what to ask if the patient has had a stroke or diabetes and frequently forgets to ask about medication allergies, we are viewed as authorities.  It's certainly terrifying to know and humbling, but empowering too.  It is like a flash vision of the future, where we really will be doctors, exuding confidence and actually knowing some of the answers.  I had a moment in ambulatory care in the first semester, where we go and shadow a primary care physician in the area, when I was able to follow up with a patient.  She'd been someone I expected to be difficult when I met her, with several physical and psychological problems, but she and I ended up connecting.  I talked with her for a half an hour, gathering relevant history and advising for weight loss.  I left with an encouraging smile, and was blown away when three weeks later, she came in again and remembered my name.  When I saw her with my preceptor, she acknowledged to have followed some of my diet advice, and she hadn't gained any weight in the time in between.  I was blown away.  A patient actually followed my advice?  It made my month.

(3) Coffee really does work.  This is not to say I am addicted--I am working really hard to keep my consumption to a minimum.  And no, I still don't like the taste of coffee--I have to have cafe au lait or a latte or anything that is at least half milk.  I have discovered, however, that on days where I have not gotten nearly enough sleep and I find my eyes getting heavy or my mind stalling over the same five words, the caffeine in coffee does bring me that needed burst of energy and helps me to focus more.  Whether the effect is psychological or not, I haven't tested, but it does work.  That being said, I can't do more than a medium, ever.  Sometimes even with that, if I am not sufficiently sleepy, I can feel the caffeine in my blood like tiny bubbles, and it feels as though everything is going on warp speed.  It's all a matter of spacing and planning :) 

(4) There's something for everyone.  Well, mostly at least.  My favorite module of the year was viruses.  That something essentially non-living to be so destructive and so elusive of nearly all medications just blows my mind.  I have quite a bit of respect for these little particles as pathogens!  My friend meanwhile far preferred bacteria to viruses.  Others loved cardiology, neurology.  It will be interesting to see how all my classmates and I like our rotations next year and what we all end up going into. 

(5) Medicine is truly a calling and privilege.  Though or patient interaction was mostly minimal this year, every one reminded me why I love medicine and why plugging through these didactic years is SO worth it.  Just being able to hear fragments of people's stories and to sit in a room with them and figure out how to connect with them on a very human level is powerful.  I admire the strength I see in most of the patients, how one can be a 49-year-old former addict and now diabetic with ulcers on 20 medications and still light up when she talked about her grandchildren, or how one can be depressed with multiple ailments and exhaustion written on her face yet find the energy to joke with us.  There truly is nothing else I would want to do with my life. 

For those who stuck with this very long entry, thanks :)  I will try and be much, much better with writing this year.  I leave tonight for Cambodia, where I will spend three weeks working in a hospital in Siem Reap (where the temples of Angkor Wat are) doing what is essentially a rotation.  It was time to try something more clinical for me.  When I come back, rotations start and I will begin with OB/gyn at Washington Hospital Center for six weeks.  Blessings and love to all!

Sunday, August 28, 2011

Adventures Since Being Back

Sorry for the hiatus since coming back to the US--it has been a bit of a whirlwind (but then again, when is my life not?), visiting friends and family in NY, then starting classes almost immediately after being back in DC.

Being a second-year medical student certainly feels a little surreal. It is a step closer to the dream, and this year, we focus on the more clinically relevant aspects--pharmacology and pathology (so basically drugs and diseases). I love it. We learn pharmacokinetics and mechanisms, which satisfies that part of my brain that constantly asks why things happen the way they do. We are also currently studying immunology, which I love. Really--the human body is phenomenal and immunology is just one example of how phenomenal. The system is so complex and intricate, and yet miraculous. Did you know we make all of our antibodies at random and before we see any disease? And yet somehow, we manage to be able to fight most bugs that come our way. There are so many steps, checks and balances, compensatory mechanisms. Truly, we are fearfully and wonderfully made!

In the past week, my friend from Trinidad has been visiting. He was looking for an excuse to come, and he picked the ideal week (just before life starts to become insane and clubs and academics become the routine and necessity). Of course, he also happened to pick the week of natural disasters in DC! Tuesday, we were having a late lunch when we felt shaking that felt like the metro struggling underneath (except that I knew the metro was a block over) and the glasses rattled a bit. I had no idea what happened until one of the other women said I think we just had an earthquake. Surprise! That we had one in DC at all made me wonder, but we just went outside, were served our lunch, and continued with our day. And of course last night, the hurricane, which really wasn't bad either. The only downside was that the heavy rains caused my windows and ceiling to leak, and so a steady drip-drip-drip serenaded us all night (and continues, albeit more slowly; I can see the drip into the saucepan and the subsequent rebound). Still I am grateful all is all right in most places, as far as I know.

Who knows what other adventures the year holds? I will do my best to keep you posted somewhat, or at least better than last year. I am excited to learn about diseases and treatments, to feel maybe a little more like a doctor, to see what changes the city has in store for me now. I am glad to be here, though I miss Cambodia, and grateful to have had that experience as well. And for future reference, not being able to sleep on planes does help a bit with jet lag :)

Sunday, July 31, 2011

Week Off--Phnom Penh

The crew had the past week off--vacation for them, and for me, it was supposed to be an easier week in which I caught up with my research data, read, and relaxed. It was a relaxing week, but little research got done, and it was not quite as quiet as I expected. I did a lot of cleaning--dishes, laundry, even some of the kitchen (after I spilled oil all over everything). I realized that even cleaning could take on a sort of meditative element (no, this doesn't mean I will clean more, it just means that cleaning intentionally makes it almost meditation, though I did take frequent breaks!). After the day Marie Claire and I spent cleaning though, Bill came down and told us he would take us to dinner in town (Phnom Penh)--we went to a beautiful hotel with a delicious buffet, and even got a bit of Filipino music before we left!

I had the chance to experience a bit of the Phnom Penh market scene this week. On Monday, the PIP manager in Cambodia, Somnang, dropped me off at the market with 40,000 riel or $10US and an order to buy some fruit and vegetables so we could eat in our week without the cook. I moved between vendors with magenta dragon fruit, pink and black rambutans, plum-colored mangosteens, some healthy and some wilting heads of lettuce, plump carrots, and a myriad of other things. How much? I would ask, pointing at the desired item. Each vendor would reply with the price in Khmer, but we understood each other no problem. I got 1kg of lettuce for 2500 riel, or about $0.50, a kilo of dragon fruit for about 3000 riel ($0.75), and other prices that would shock a Westerner--prices as good as our Khmer cook gets, which made me proud of my shopping skills. Even my tuk-tuk (moto with a cart attached) back to the ship was only 5000 riel, which was a lot for the trip, but not for a foreigner. This morning, I had a different kind of market experience--I went with the cook to buy fruit and vegetables for the week (we will be moving for two days, so there will be no ability to get to a market). The market truly is a sensory overload--a cacophony of sights, sounds, smells. Again, the vivid colors of the fruits and vegetables stood out. Rain poured from the sky, courtesy of a storm over the South China Sea, in between tarps for the vendors, into buckets, keeping merchandise remarkably dry, but legs and ankles mud-streaked. There were fruits and vegetables, brooms, meat. Some sold pig ears, intestine, frogs. Some crabs were still crawling out of the bucket, some of the fish still flopping--nothing like fresh! I tried to take it all in, all the produce, the way in which the cook talked the vendor down on the price of bananas, which vendor had the best-looking tomatoes, all the while making space for other customers and dodging the motos trying to get through. It was exhilarating, and really, a lot of fun.

Other than stay on the ship and do a bit of research and a lot of cleaning, I also got a walking tour of Phnom Penh, courtesy of Lieng, the night guard (we left at 6am), Sanh, the cook, and Jack, the electrician. We walked by the Independence Monument commemorating Cambodia's independence from France in 1953, a year before other Indochinese nations like Laos and Vietnam became independent. We crossed the bridge to Diamond Island where during the Water Festival last year, 300+ died in a massive but unnecessary panic (I won a mug on the island throwing darts at balloons, following Sanh's sage advice to just not think about it). We fed pigeons in front of the Royal Palace and I learned that Cambodia was once Hindu, and an old woman created the city's temple on a hill. It was great exercise, great learning, great company.

In the morning, the ship will move up 140km to the entrance to the Tonle Sap Lake, where it will spend the next six months. On Tuesday, I leave the ship and on Wednesday, I leave the country. It will break my heart to leave--I have once again fallen in love with the Khmer people and the kingdom of Cambodia, and I have made many wonderful friends among the crew. It is truly a blessing to have been able to be here for seven weeks. Thanks to all for your prayers and love, and I will catch you all stateside!

Saturday, July 23, 2011

Last Week of Clinic

Time in Cambodia has an incredible way of both lingering and passing too quickly. Already, I am six weeks into my time; already, I have to think about returning to the US and to medical school. Already, my time with the clinic has come to close. Because Aug 1, the ship travels two days to move to the Tonle Sap Lake near Siem Reap/Angkor Wat, which is far from Phnom Penh and most of the crew's families, they get this coming week off--all but a few are home at this point. It will be both a blessing and a curse--a blessing because it is a quiet week, where I will be able to relax and work on putting some of my research together, and a curse because I love the clinic, I love working with the Khmer patients and witnessing their kindness and the kindness of the crew. It is as it is though, and I know this will benefit all, and I am happy for the crew, for their time with their families.

Clinic on the ship works half like a well-oiled machine and half like organized chaos. 20 patients come in at 8am, up the gangplank and up the stairs. Children, mothers, fathers, men and women in their 80s, all traipse up the steep ship stairs for triage--blood pressures and temperatures. They come down in clusters of five for the doctor, of four for the dentist. When I am not interviewing or doing something else, I am standing downstairs, making sure everyone sits where they're supposed to, people see the doctor in something that resembles number order, and that everyone is ok while they wait. Or mostly, I try to speak Khmer and smile, or play with the children or sit with the old women, while they try to speak to me in Khmer or tell me my nose is beautiful. We delight each other, and it is beautiful.

The Khmer doctor will see 80 patients a day, every day, and the dentist will see 35. Everyone is grateful and excited--very few appear pushy, too eager to see the doctor, though a few are disappointed when they do not receive a slip to get the glasses the ship gives out to those the doctor says would benefit. I understand now when people tell me about their eyes. I nod and say (in English because I do not know the Khmer), yes, tell the doctor.

The beautiful thing about clinic is that I have the opportunity to interact with nearly every person who comes on the ship. Whether I check their number as they come in, tell them to go up the stairs, help them down the slippery gangplank after rain, or tell them the doctor is ready, I see nearly every face at least once. Everyone has a smile. The last village we were in was poor despite its proximity to Phnom Penh, some of the patients and children came in dirty and probably hungry, and yet everyone looked kindly at me, many put their hands together in the Khmer greeting of respect and thanked me as they left. There is such a sense of mutual love every day--it is energizing and utterly amazing.

Now the ship is in Phnom Penh. Acrobatics from Piseth, who I am convinced is Superman because he can literally do almost anything and Kha, who is just amazing in his quiet work ethic and huge heart, helped us tie the ship down next to a boat in dry dock. We have to walk down three gangplanks and two boats as well as cross a bit of the river on a raft made of a metal grate and four empty barrels to get off the ship. At night, we can see the multicolored lights of the ferris wheel across the street and the tour boats. It's a different world here than in the villages for sure, though still quiet in its own way.

Be blessed and well!

Saturday, July 16, 2011

Many Words for Perfection

There are many words for perfection, but few can come close to describing the elements of the last evening in Cambodia. We worked yesterday (Saturday) so the crew can have a full week off starting the 24th, before it moves up to the Tenle Sap lake, which is about four hours from Phnom Penh, where many of them live. The day was peppered with little children (two of whom peed on the floor in a span of five minutes--babies in Cambodia don't often wear diapers, because parents cannot afford them), some of whom were precocious, all of whom were absolutely adorable. There was an impossibly fat little baby that laughed without teeth, a little girl who could speak a few phrases of English, another little girl with pigtails and missing front teeth, and a boy who put three or four stickers on his face. Children are a delight--and you don't need language to communicate. All you need are smiles and hands and a playful spirit. There are few things that can lift a moment of frustration like a child, or like one of the old women in Cambodia who continue to smile and tell me my French Canadian nose is beautiful.

Once the crew left for the night (most went into Phnom Penh for the night--the ship is very close), I watched the rainclouds move (which has become a favorite pasttime...Cambodian rainy season pre-storm winds carry such energy!) over Phnom Penh to the other side of the river and helped the cook make chocolate-filled sweet rolls, when suddenly I noticed--a rainbow! I love rainbows--there is something so breathtakingly spectacular about them. They often appeared in Trinidad in the rainy season, sometimes full, vibrant arcs, sometimes two. I get so excited at the simple beauty, but usually cannot say a word, lest people think I am insane, but because the crew members here are my friends, they watched as I tried to get them all to notice (and fortunately, one of them was equally as excited and another just watched with amusement as I got even more excited when a second rainbow became visible) and took a few pictures. Later, I finally got the sunset I had been waiting for all week (there had been a beautiful one Monday night, but I did not have time to get my camera in between English classes), played Monopoly cards with the other Americans on the boat (at the moment, there are five of us, with two more returning from Ankor Wat tomorrow), and came out to the moon making me catch my breath. In a few days, it will be full and by the time I was outside today, it had already risen to a decent height, but it lit the bank up and made the river sparkle and gleam. Even though the Mekong is brown from silt and often filled with litter, most of the disappears when it becomes shades of almost-black at night, and it completely fades from memory when shining with the moon.

Today will be quiet--filled with the interview transcripts on which I am behind (again), reading on the deck, and perhaps a walk through the village. Tonight, we have our worship service. I love worship here--it is so simple, in the ship's dining room, and the lessons must be translated, so they too are simple, but often eloquent. My favorite is singing though--singing in English is difficult for the Khmer, and none of us Americans know how to sing in Khmer, but something about the mix of off-key melodies feel very much like prayer, and the enthusiasm with which they are sung most certainly must be. A few weeks ago, we sang "Yes, Jesus Loves me,"which makes me smile anyway because I remember learning it in kindergarten, and I remember the captain singing softly for most of the chorus until he got to the "loves me,"which he belted out. Even the memory of it makes me smile. I especially love when we sing in English and Khmer together.

It is a complete privilege to be able to be in Cambodia for seven weeks in my last real summer vacation ever. The people here are so kind and generous, always willing to share a smile or call out "hello!" They are all so gracious to me as a foreigner, and my Khmer has improved by leaps and bounds (which still doesn't say much, given that I know very, very little Khmer)--I can communicate just a little, and I have a few excellent Khmer teachers (and a very, very disorganized piece of paper nearly entirely covered with phonetic pronunciations of Khmer vocabulary). Thank you for the love and prayers, and I wish you all blessings.

Sunday, July 10, 2011


Cambodian villages are a delight to walk around in. The roads are dirt, even in this most recent village, where it is easily wide enough for two cars (cars are rare; I've only seen them close to Phnom Penh, and close to Vietnam). Pavement doesn't happen except in main roads and Phnom Penh. Many people ride by on motos with surgical masks for the dust. Motos are the most popular form of transportation. Apparently there is a law now limiting the number riding to two, though I've still seen three or four people in the villages themselves, particularly if a few of them are children (and I've ridden one with four of us total), though not the six that Bill (the NGO founder and ship manager) had once seen. The wealthier villages have more motor bikes, whereas the poorer ones have more bicycles. Often rusty, the bicycles astoundingly still manage to get people from point A to point B, often with stacks of fruit from the market, maybe rice, maybe Khmer cakes to sell. Children will ride bikes three sizes too large for them, maybe seven years old on a bike designed for an adult, and will carry younger siblings on the handlebars or standing just in front or just behind them. It always works, and what truly amazes me is the lack of fear.

The village we are in right now, maybe 20km and across the river from Phnom Penh, is one of the wealthier ones I've seen. Wealth is determined by things like the size of the house, whether a car is present, if the floors are tiled. Homes here seem pretty large, and they receive electricity for the most part, likely from Phnom Penh. Large here is not large by US standards--large here is maybe three or four rooms, elevated by steps and poles from the road. Still too, the larger houses are intermixed with those where bamboo makes up the walls and thatch (which must be changed every few months) makes up the roof. Like everywhere though, children come outside and play and delight in yelling hello to the foreigner as she passes. (In one village, a boy of about 3 with a mullet called to me and Marie-Claire, hello, barang! (barang meaning foreigner, particularly French).) One yesterday, playing soccer with his friends, shouted hello, and as Bunthoeun (the clinic assistant) and I passed, asked why you no play? I do so love the children!

Last week in the clinic, we had a nurse practitioner from the US as well as the Khmer doctor, so we saw close to 140 patients each day (plus the ship now has a Khmer dentist, and he saw about 30). It is always amazing to be able to hand out more numbers at the end of the day when we have time to see more, but also amazing to see how many more people come out when we take more patients. Last week Thursday, the line exceeded 200 and snaked down the road, and then curved towards the river. I caught my breath--so many people. No matter what, no matter where. People tell me sometimes they forgo the medical care they need because of their living standard--they simply don't have enough money. It breaks my heart that people must make a choice to receive care or eat. I am grateful to play even a small role in the work the ship does--though many are not seriously ill at the moment, because simply being present and giving medicine is healing in a sense.

And the medical student in me must express my gratitude to the nurse practitioner, Clay, who was here last week and to the Khmer doctor, Dr. Tha, for teaching me! I saw an incredible jugular venous pulse (something we've heard in three or four physical diagnosis lectures) and an inguinal hernia in a 9-year-old, listened to lungs with bronchitis, and learned what we give for epilepsy. Really, I love the experience. I love the people I work with every day, the ship's crew, who all love to learn and talk with me and teach me about themselves and their country and who can always make me smile. I love the patients who come on, particularly those who want to trade noses or marry me to their sons, the babies with their chubby cheeks, and those who smile, whether with one tooth or 32. God bless Cambodia, and God bless you all as well. Continue to be well!