After graduation, Michael and I planned a small road trip for just the two of us. We ended up making the 7.5 hour drive from Iowa City to Sandusky, OH on Thursday, so that Friday morning we could wake up and go to Cedar Point Amusement Park and ride roller coasters. I had hoped it would be a hot summer day on May 24th, but unfortunately it was cold and windy. The benefit to bundling up in jackets we usually wear in the winter is that we had zippered pockets where we could "secure loose articles." I had also hoped the lines would be shorter because we avoided the weekend and went on a Friday, but unfortunately there were buses and buses full of kids on end of the year school trips. Even considering these things, we had a great time.
Michael had looked up a couple of roller coaster rank lists and was very excited that Cedar Point had 4 in the top 30 of one list, and another list had different roller coasters in their rankings. We decided to try and ride every coaster, in order to make our own rank list. Around 2 when we went to the car to make our lunch, I was very concerned we wouldn't be able to do it, because the lines were so long. Three or four of the roller coasters had wait times over an hour and a half. The longest line we waited in was for their new roller coaster called GateKeeper. It had only opened 2 weeks before we got there, and we waited for a little over an hour and a half. Even though we waited so long, I felt good about it as we neared the front and looked back to see the end of the line extending even further back in the maze of railings.
By 5 in the afternoon, I started to think we would be able to ride all of them, because the lines started shortening. I think we would have done it, but when we arrived at the last 2 on our list they were closed for mechanical problems.. We ended up riding 10 of 14 roller coasters, and we were able to ride the one at the top of our list twice. Raptor and Wicked Twister we couldn't ride because of maintenance, and two others we chose to pass up because they were described as a black diamonds instead of black double diamonds (we rode one black diamond coaster and it was decidedly less aggressive and thrilling than the others).
Our Ranking...
1. Maverick. A western themed coaster. It's unique characteristic is that after it shoots you quickly up the first hill, the slope goes past vertical on the way down. There are lots of twists, but the ride is smooth and not bone-jarring. 3/4 of the way through the ride you enter a tunnel and slow nearly to a stop. Then the ride shoots you out of the tunnel, probably the fastest acceleration of the ride. This was obviously our favorite, and remained at the top after our second ride. :)
2. GateKeeper. This ride is touted as a "record breaker" for being the coaster with the highest point of inversion. That's all good and fine, but it is not why we liked it best. The seats are arranged in a bat wing fashion, so there are two seats on either side and looking across to the other set of seats, the rail is just below eye level. It makes you feel like you are on the wings of a plane, and when the coaster twists it is like the plane is banking. This is especially exciting when it comes to the gate. The coaster got its name because it is located at the front of the park and the front gate has two towers going up, like the prongs of a plug-in. Also like the prongs of a plug in, the towers have holes cut from the middle and the track goes through these, like threading a needle. As you first approach the tower, the car is horizontal and you feel like the bat wings will get clipped off. Of course the car twists and you slide through - just like you were flying through canyons or the maze of the Death Star.
3. Consistently ranked as one of the world's best steel rollercoasters, Millennium Force is our third favorite in the park. It doesn't have loops or twists, it's main thrill coming from speed and height. You're pulled to the top of the hill with the same slow steadiness I remember from roller coasters as a kid, the anticipation and the height almost dizzying (plus the incline is at a 45 degree angle to the ground - super steep!). I wasn't so scared that I didn't appreciate the moment to look around and take in the view of the lake. Then you're over the crest and zooming down. I had to check online, because I couldn't remember all the speeds from the day, but this one reaches 93 mph and that first lift hill goes up to 310 feet.
This is where our lists start to look different. I think Michael ranks Mean Streak next, but I'm going to go ahead and stick to my list.
4. Top Thrill Dragster is definitely built for height and speed. It was the tallest and fastest roller coaster in the world for 2 years after it was built in 2003, reaching 420 feet and 120 mph. Even though it goes 100 feet taller than Millennium Force, you spend much less time at those heights and so you don't get to look around or psych yourself out too much. Also, it's super short. You basically zoom out, getting up to 120 mph in 4 seconds, then go straight up to 420 feet, turn around and come straight down. After that you stop and roll back into the station. It's only as high in my ranking as it is because of the novelty of its height and speed.
5. Magnum XL-200. This roller coaster was built in 1989 and was revolutionary. It was the first complete loop steel coaster to go over 200 ft. Compared to the new roller coasters, it doesn't really compete, but it is a quality ride all the way around with good variety. I especially liked all the little hills it has because I like the feeling of my stomach coming up into my throat (weightlessness?).
6. Gemini. This wooden coaster is named because it has two tracks running side by side, but we road it when only one track was running. It predates Magnum, but is another exciting and enjoyable ride. It comes higher in my list than Michael's because of the importance I put on those hills and weightless feeling.
7. Corkscrew. Also a pre-90's coaster, this one is steel with three inversions, one of which brings your right down over the sidewalk so that you feel like you can touch the heads of the people beneath you (of course there is a grate directly in between). Looking back on this one, I am fond of it, but it featured upside down tricks instead of weightless sensation hills.
8. Mean Streak. This ride is the last wooden roller coaster we made it to. It is in the far corner of the park, and even when all the other lines were half an hour, this one was less than 15 minutes. It was high and had lots of hills, but it was too rattly for me to really enjoy it. I didn't even get the sensation of falling as we went down the first crank hill. The thing I was most amazed with on this one was how long the ride lasted. We kept going and going, racing along within an arms reach of the supports of the track we'd just come from or were soon headed to.
9. Mantis is a stand up roller coaster, but besides that, it wasn't anything special. I bonked my head and hurt my ears on the head rest, and got off of it complaining that it rattled my bones too much. Also, I think it was more of a twisty, inversion thrill ride than a weightless thrill ride, and it really emphasized the twists.
10. Iron Dragon. I'm starting to think this one should maybe go ahead of the Mantis, mostly because I was really uncomfortable on the Mantis. But it sits at the bottom of the rankings because it wasn't very exciting. It wasn't thrilling, but it also wasn't uncomfortable. A good ride, just not a special roller coaster in a park filled with special roller coasters.
Monday, May 27, 2013
Tuesday, May 21, 2013
Graduation
Today is day number four since earning my Doctor of Medicine degree. Of course I don't feel any different, and I think there was more hype leading up to my high school graduation. Strange, considering this is a degree I can actually do something with.
But I guess I couldn't have gone to college without graduating high school, and I couldn't have started medical school without college - so they are all linked.
Maybe high school graduations are easier to celebrate because there is a very established routine. The community where I grew up expected senior pictures, which would then be used to make graduation announcements/invitations. The invitations would all reference weekends in May, which are thus expected to be busily spent attending various graduation receptions. The receptions are easily hosted by parents in houses or community buildings.. as opposed to college, where such large gathering spill out of dorm rooms or "bachelor pads."
Another contributing factor to graduation from high school being a more celebrated event could be that there were more people paying direct attention to what I did when I was in high school. Or, if people were not paying attention to the four years during high school, they may have been involved in the 14 years preceding it. The celebration of high school graduation is not only for accomplishments achieved during high school, but for all the years of life preceding it as well.
With hype or without, graduation from medical school is an accomplishment to be proud and excited about - which I unfortunately had to be reminded of in the staging area before commencement. With all the stress of corralling my family from place to place on graduation day, I'd started to forget the purpose of the day. When my friend asked me how I was feeling and my response was less than enthusiastic, he reprimanded me and suggested I take a step back to look at what we'd done. What did we do? We studied really hard to learn facts and details. But everyone knows that. What else? We spent time reflecting on many of the ethical issues and questions that are presented to physicians daily. We practiced writing patient encounter notes, long and time consuming at first, little by little becoming more efficient. We put ourselves in uncomfortable situations because we needed to learn. We bumbled through presentations, hoping that repetition would make us less bumbly. We changed our sleep schedules to match whatever hospital schedule was needed, and frequently woke up at hours that other young adults see as bedtime.
Maybe most importantly, we learned that we will always be learning. It is easier for me to look ahead and recognize all that is left for me to learn than it is to look behind and recognize all the knowledge I have gained. Talking to Liz, who just started medical school this year, is helpful for realizing how much I have learned. It is especially encouraging after a rough day "at work" where it felt like I didn't know or recognize anything, to come home and explain something - thus validating that the 4 years of study were not, in fact, wasted.
But I guess I couldn't have gone to college without graduating high school, and I couldn't have started medical school without college - so they are all linked.
Maybe high school graduations are easier to celebrate because there is a very established routine. The community where I grew up expected senior pictures, which would then be used to make graduation announcements/invitations. The invitations would all reference weekends in May, which are thus expected to be busily spent attending various graduation receptions. The receptions are easily hosted by parents in houses or community buildings.. as opposed to college, where such large gathering spill out of dorm rooms or "bachelor pads."
Another contributing factor to graduation from high school being a more celebrated event could be that there were more people paying direct attention to what I did when I was in high school. Or, if people were not paying attention to the four years during high school, they may have been involved in the 14 years preceding it. The celebration of high school graduation is not only for accomplishments achieved during high school, but for all the years of life preceding it as well.
With hype or without, graduation from medical school is an accomplishment to be proud and excited about - which I unfortunately had to be reminded of in the staging area before commencement. With all the stress of corralling my family from place to place on graduation day, I'd started to forget the purpose of the day. When my friend asked me how I was feeling and my response was less than enthusiastic, he reprimanded me and suggested I take a step back to look at what we'd done. What did we do? We studied really hard to learn facts and details. But everyone knows that. What else? We spent time reflecting on many of the ethical issues and questions that are presented to physicians daily. We practiced writing patient encounter notes, long and time consuming at first, little by little becoming more efficient. We put ourselves in uncomfortable situations because we needed to learn. We bumbled through presentations, hoping that repetition would make us less bumbly. We changed our sleep schedules to match whatever hospital schedule was needed, and frequently woke up at hours that other young adults see as bedtime.
Maybe most importantly, we learned that we will always be learning. It is easier for me to look ahead and recognize all that is left for me to learn than it is to look behind and recognize all the knowledge I have gained. Talking to Liz, who just started medical school this year, is helpful for realizing how much I have learned. It is especially encouraging after a rough day "at work" where it felt like I didn't know or recognize anything, to come home and explain something - thus validating that the 4 years of study were not, in fact, wasted.
Sunday, May 5, 2013
An Easter Poem
I am copying this from a bulletin. It doesn't say who the author is.
An Easter Poem
Love is hard
as nails
And life, a gift
as tender and precious
as the morning dew.
Come, now. Wake up
and be glad.
An Easter Poem
Love is hard
as nails
And life, a gift
as tender and precious
as the morning dew.
Come, now. Wake up
and be glad.
Tuesday, April 16, 2013
Spring
Because of a combination of having a whacky ER schedule and April being unseasonably cold, I haven't been outside to run much this spring. I saw the sun peaking out today, and, deciding to be more productive than yesterday, I left for a run.
I ran down to Gray's Lake and around. The City of Des Moines has some kind of program going on and there were signs hung in the trees all around the lake. As far as I could tell, the signs all had haiku's printed on them. In two places around the lake, they had big blackboards and chalk for people to write their own haiku, message, or thoughts. A sign suggested writing your own haiku, so I tried thinking of one as I ran, and this is what I came up with...
feet hit the soft ground
cool air, warm sun on my face
first runs of springtime
On a separate thread, right where the sidewalk from downtown DM meets up with the trail encircling Gray's lake, there is an eagle's nest. When I arrived at the lake, I thought I saw a big dark thing in the next with a white part on top that moved, but I just couldn't be sure since I didn't have my glasses. When I completed the circle, there were 2 people on the sidewalk with tripod-ed viewing devices (one was like a telescope, the other was clearly a camera). I stopped to talk to the camera guy and he said both adult bald eagles were at the nest (confirming what I thought I saw as I approached) and that they were feeding the baby. He let me look through the viewfinder on the camera and right away I saw the little bird poking its gray head up and grabbing at whatever food was offered by it's parent. Really cool, and a good reward for getting outside today!
I ran down to Gray's Lake and around. The City of Des Moines has some kind of program going on and there were signs hung in the trees all around the lake. As far as I could tell, the signs all had haiku's printed on them. In two places around the lake, they had big blackboards and chalk for people to write their own haiku, message, or thoughts. A sign suggested writing your own haiku, so I tried thinking of one as I ran, and this is what I came up with...
feet hit the soft ground
cool air, warm sun on my face
first runs of springtime
On a separate thread, right where the sidewalk from downtown DM meets up with the trail encircling Gray's lake, there is an eagle's nest. When I arrived at the lake, I thought I saw a big dark thing in the next with a white part on top that moved, but I just couldn't be sure since I didn't have my glasses. When I completed the circle, there were 2 people on the sidewalk with tripod-ed viewing devices (one was like a telescope, the other was clearly a camera). I stopped to talk to the camera guy and he said both adult bald eagles were at the nest (confirming what I thought I saw as I approached) and that they were feeding the baby. He let me look through the viewfinder on the camera and right away I saw the little bird poking its gray head up and grabbing at whatever food was offered by it's parent. Really cool, and a good reward for getting outside today!
Wednesday, March 27, 2013
Summit of Kilimanjaro!
On Tuesday, March 5th at 8:45 in the morning,
Kendra and I reached the summit of Mt. Kilimanjaro. It is called Uhuru peak and
is the highest point in Africa. As a fellow summit-reacher explained, “I
wouldn’t call it fun, but it was worth it!”
Our schedule on the day of summit was a little different
than we originally thought based on the information online. We were also the
only ones to do it differently. Our
guide, who goes by Future, thinks it is smart to wait and leave later in the
morning, instead of at midnight. His explanation is that by leaving later, you
have more time resting in your tent (maybe sleeping if you’re lucky) so then
you have more energy for the climb. You also spend less time climbing in
darkness, and the light is good for both psyche and warmth. He said that most
people leave at midnight to reach the summit in time for sunrise. It is also
traditional to go a midnight because it used to be that you had to walk on a
glacier to reach the summit; you wanted to cross the ice before the sun came up
and it became slick due to melting on the surface of the glacier. Our plan had us leaving Barafu camp(4,600 m) at 3am (we actually left between 3:20 and 3:30
am) so that we could reach 5,000 m in time for the sunrise. 5,000 meters is the
magic elevation because above that there aren’t ridges to block the view.
The first 3 hours we climbed in darkness, using our
headlamps to see where to step. I was glad I got to sleep some more and I
didn’t feel so very tired, but I also didn’t feel energetic and I didn’t like
not being able to see very much. The sun rose around 6:30 and we had a clear
view of it as it came above the Mwenzi peak to the east of the Kibo peak we
were climbing. Actually, the sun came up between two layers of clouds, so maybe
10 minutes after rising we were back in shadows. In fact, the clouds overhead
had been obscuring the summit since probably 4 am. I don’t know if the
people on the summit at 6:30 saw the sun come above the clouds that were
above us or if they were in the clouds and didn’t really get a view of the
sunrise at all. I liked my experience though and wouldn't change our later start time!
Once the sun was up, the mood was lighter. We could look out
and see valleys with clouds rolling in, we could look back down and see our
camp, and we could look ahead on the path. We couldn’t see our destination
because the mountain above us was always in clouds. We could also look from
side to side on the path, which wasn’t very interesting. Rocks, rocks, more
rocks. Big and small rocks. Rocks that are a favorite site for a bathroom stop
(I saw a pile of fresh feces less than 2 meters from the path once). 
Right
before reaching Stela’s point, there is a very difficult stretch. It is
difficult because the usual scenery of rocks has changed to mostly sand. As
anyone who has tried a beach workout can attest to, going places on sand is
extra work compared to going places on solid surfaces. Luckily for us, the
people that had been to the summit around 6 were now reaching us on their way
down, and it was nice to hear some encouraging words from them. Around 7 am,
the clouds cleared and we could see Stela’s point. We kept going on the loose
sand and then reached Stela’s point around 8:00. Stela’s point is an exciting
place to reach, because after that the hiking is a “piece of cake” according to Future. 
At first we were skeptical of the “piece of cake” hiking,
but it really is much easier – you follow along a ridge that is never
very steep and the ground is not too loose. 45 minutes after Stela’s point, we
reached our goal! Yay! A few photos… and down we go.
I think Future was anxious to show us that his plan was
superior to leaving at midnight. When we passed people on the way down he
always said, “See, they have no energy.
They are exhausted.” Which looked to be true. However, we were also
exhausted. He kept us moving at a quick pace (at the time I thought he was a
slave driver), and we were back at Barafu camp by 10:30. Part of the reason
that we could come down in less than 2 hours, when it took us a little more
than 5 to go up, is that we “sand ski” down much of the way. It sounds fun, but I couldn't enjoy it because I thought it was dangerous! I’ve never been skiing (snow or sand) with so many rocks and uneven
coverage. You had to be careful to not hit a hard spot and have your foot stop
too quickly so you went head over heels. I saw Kendra fly through the air once,
but she caught herself very gracefully. We both slipped and stumbled multiple
times, but luckily no serious falls. Thursday, February 28, 2013
Kilimanjaro
On Friday, March 1st Kendra and I will begin our trek up Mount Kilimanjaro. The itinerary says we start at Machame Gate (1800 meters) and walk through a rainforest type environment to the Machame Hut camp (3000 meters). The next day, we leave Machame to get to Shira camp (3840 meters). This is a 4-5 hour hike in mooreland. Sunday is an important day for acclimatization, as we will go as far as “the junction of Lava Tour” at 4600 meters before returning to Baranco camp at 3950 meters. Monday we “ascend the great Baranco wall” which is reported to take 1.5 hours (is that just the wall, or the whole day’s hiking? I don’t know) and then end in Karanga Valley (4100 meters). Tuesday we leave our camp in Karanga Valley and arrive at Barafu hut (4600 meters) in time for lunch. Hopefully we will be able to go to bed and sleep early in the night, because in the wee hours of the morning we will get up to make the last leg of the journey to the summit. The schedule I have says we will go via Stela Point to reach Uhuru Peak at 5895 meters. Take some pictures! And start the trek down…
It goes much faster on the way down. We will have lunch at the same camp as the day before (Barafu) and then descend to Mweka camp at 3200 meters. The last day (Thursday), is only a 3 hour walk in the rainforest to get from Mweka camp to Mweka gate. A car ride back to Moshi will complete our Kilimanjaro adventure. What next?
*- Safari-*
Our plan right now is to meet the DMU students that arrived on the 17th of February for a 4 day safari from March 8-11. We will definitely go to Ngorongoro crater, and hopefully we will be able to get over to see the Serengeti in that time as well. After that, Kendra and I catch a bus back to Dar where we will spend the night before flying home. Natalie and Eva, the other students, will have a few more days at Gonja before continuing their 4th year adventures in Uganda. I’m betting that I won’t be able to get on the internet again after we leave Gonja, so this is goodbye until I see you again back in the states! Thanks for paying attention to all my ramblings!
It goes much faster on the way down. We will have lunch at the same camp as the day before (Barafu) and then descend to Mweka camp at 3200 meters. The last day (Thursday), is only a 3 hour walk in the rainforest to get from Mweka camp to Mweka gate. A car ride back to Moshi will complete our Kilimanjaro adventure. What next?
*- Safari-*
Our plan right now is to meet the DMU students that arrived on the 17th of February for a 4 day safari from March 8-11. We will definitely go to Ngorongoro crater, and hopefully we will be able to get over to see the Serengeti in that time as well. After that, Kendra and I catch a bus back to Dar where we will spend the night before flying home. Natalie and Eva, the other students, will have a few more days at Gonja before continuing their 4th year adventures in Uganda. I’m betting that I won’t be able to get on the internet again after we leave Gonja, so this is goodbye until I see you again back in the states! Thanks for paying attention to all my ramblings!
Monday, February 25, 2013
Tanzania OB and HIV
It is the end of week three here in Tanzania, and I’m going to try and describe a few of the highlights from my time at Gonja Lutheran Hospital.
One of my favorite parts of medicine is delivering babies. Probably this is because it is generally a happy and exciting thing and also because you get to see the results of your work right away. I already described the first delivery we saw, and I’ll briefly mention the other obstetric events I got to participate with.
The day after the high intensity resuscitation efforts, Kendra and I were present for a vacuum assisted delivery. The young woman delivered a healthy baby girl who cried almost immediately after being born (both are in picture to the right). The interesting part of that delivery was to see the vacuum/suction device they use here. It is not a hand held self pump, but rather a rubber apparatus that has a head like a plunger. Instead of a wooden handle there is a rubber tube to connect the cup to a mechanical suction machine. Dr. Amini cut a mediolateral episiotomy (cringe!) to help place the cup on the baby’s head. Once placed, he asked the nurse to turn on the suction, and then waited a couple minutes for it to form a strong seal. After a few attempts – the seal kept breaking and he would have to replace the cup, waiting each time for a new seal– the baby was born. I delivered the placenta, and let the OB nurse stitch the episiotomy.
One week ago, I saw and scrubbed for my first C-section. There have been plenty of c-setions, but for whatever reason I never hear about them until they are already underway. In this case, Dr. Lusingu is my neighbor and this is his week of call. I asked him to get me on his way to the hospital for c-sections, and so around 2 in the morning I heard him calling for “Doctor Kendra” (Kendra is currently away, but it is not uncommon for our names to get switched here. I guess it is the similar –ndr– in the middle of them that get people confused?). I yawned all the way down to the hospital, and all the while that they were setting up. I was awake enough once the surgery started and I first assisted Dr. Lusingu. Dr. Yona did anesthesia. The surgery went smoothly and the baby was healthy. They cut a vertical incision into the skin, fascia, and peritoneum. Then a horizontal incision into the lower uterine segment.
The night after the c-section, there were 2 deliveries back to back; the second one I was in charge of guiding the baby out. It was pretty exciting to have my first hands on delivery in Tanzania. The woman did have a 2nd degree laceration, and when I was recording in the chart afterwards the nurse told me I should write episiotomy. I still don’tknow if that is because they only understand episiotomy, or if there is another reason that they want to report iatrogenic injury to the perineum instead of trauma from delivery. Whatever the reason, I refused and wrote “2nd degree laceration” because that is what happened!
On Sunday, February 17, two new DMU students arrived. They will be here for 4 weeks and are living in the same house as me and Kendra.Their names are Natalie and Eva and I have enjoyed their company. We have fun talking about things we have in common, as well as sharing about our different experiences and knowledge. For example, Natalie grew up in Key West, and recognizes many more of the plants here. She has been sharing some of their names with us. Eva grew up on a farm in Oregon and did goat and pigs for 4-H. She has educated us some about goats, since we see them frequently grazing by the road/path.
Last Thursday night, there was another vaginal delivery. We were called at 2 am and all 4 trooped down to participate as we could. I felt that I shouldn’t hog all of the deliveries, so Natalie delivered the baby. It was her second time delivering a baby, and the first time repairing a perineum. She did a good job, and asked at times for advice/suggestions. It was strange to be helping her, because I feel like my training or experience isn’t that much more than hers. I guess I have sought out more OB experiences than she has, because her particular interest is in HIV care and treatment.
Because Natalie is hoping to care for HIV patients in the future, she is especially excited for Thursdays here at Gonja, when there is an HIV clinic in the Care and Treatment Center (CTC). This week was actually my first time in the CTC and it was interesting to see the routine in clinic. With every patient, they go through a questionnaire to screen for tuberculosis, as well as asking about other signs of opportunistic infections or medication side effects. They have a flow sheet that makes it easy to compare symptoms from previous visits as well as weight gain or – more likely – loss. Most patients seemed healthy by just looking at them, but one woman had lesions that were very clearly Kaposi’s sarcoma. She also had a lot of swelling in her right leg only, to the point that we got worried about elephantiasis and felt the need to think about tropical medicine and clarify the filarial diseases in our heads.
I think that for awhile, the people at Gonja considered HIV to be a disease of the cities and if a patient was positive it was because they had traveled to Dar Es Salaam, or Moshi, or some other big city.That it no longer the case. We have seen many patients with HIV; some patients are new diagnosis and others are known cases that come in because they are very sick. One HIV positive man in his 30’s or 40’s came in with severe shortness of breath. He had a serious case ofheart failure – not only was his JVD the most prominent I had ever seen, his anterior jugular was also distended, and the small thyroid veins were clearly visible. He did not live 24 hours after being admitted, and the doctors attributed his heart failure to the virus (I think dilated cardiomyopathy is a known complication of HIV, maybe that caused his decline). Another patient was brought in with altered mental status and cranial nerve findings (left sided facial droop and disconjugate gaze). His “blue card” that the government gives to all HIV patients indicated that he hadn’t been taking ARV therapy since 2010. That meant that he could have a number of infections affecting his brain, and Gonja doesn’t have the diagnostics to determine which organism is most likely. Instead of diagnosing, apply the shotgun approach – the patient got antifungals, antibiotics, and of course was restarted on antiretrovirals!
The topic that merges HIV and OB is Preventing Mother To Child Transmission (PMTCT). They are very careful about checking a new OB’s HIV status, even requiring both husband and wife to come to the first OB visit together so that both partners can be screened. The charts have a number designation written on them to communicate the HIV status. If the result is not known, the woman is PMTCT 0. If the result is positive, she is PMTCT 1, meaning she has HIV and needs to receive ARV therapy. If the result is negative, the woman is PMTCT 2. There have been a few PMTCT 1 deliveries, but Kendra and I always missed them because they happened in the night or they didn’t tell us they were going to C-section. However, we did see that they are careful to document delivery of the correct medication to both mother and baby to prevent transmission.
One of my favorite parts of medicine is delivering babies. Probably this is because it is generally a happy and exciting thing and also because you get to see the results of your work right away. I already described the first delivery we saw, and I’ll briefly mention the other obstetric events I got to participate with.
The night after the c-section, there were 2 deliveries back to back; the second one I was in charge of guiding the baby out. It was pretty exciting to have my first hands on delivery in Tanzania. The woman did have a 2nd degree laceration, and when I was recording in the chart afterwards the nurse told me I should write episiotomy. I still don’tknow if that is because they only understand episiotomy, or if there is another reason that they want to report iatrogenic injury to the perineum instead of trauma from delivery. Whatever the reason, I refused and wrote “2nd degree laceration” because that is what happened!
Last Thursday night, there was another vaginal delivery. We were called at 2 am and all 4 trooped down to participate as we could. I felt that I shouldn’t hog all of the deliveries, so Natalie delivered the baby. It was her second time delivering a baby, and the first time repairing a perineum. She did a good job, and asked at times for advice/suggestions. It was strange to be helping her, because I feel like my training or experience isn’t that much more than hers. I guess I have sought out more OB experiences than she has, because her particular interest is in HIV care and treatment.
I think that for awhile, the people at Gonja considered HIV to be a disease of the cities and if a patient was positive it was because they had traveled to Dar Es Salaam, or Moshi, or some other big city.That it no longer the case. We have seen many patients with HIV; some patients are new diagnosis and others are known cases that come in because they are very sick. One HIV positive man in his 30’s or 40’s came in with severe shortness of breath. He had a serious case ofheart failure – not only was his JVD the most prominent I had ever seen, his anterior jugular was also distended, and the small thyroid veins were clearly visible. He did not live 24 hours after being admitted, and the doctors attributed his heart failure to the virus (I think dilated cardiomyopathy is a known complication of HIV, maybe that caused his decline). Another patient was brought in with altered mental status and cranial nerve findings (left sided facial droop and disconjugate gaze). His “blue card” that the government gives to all HIV patients indicated that he hadn’t been taking ARV therapy since 2010. That meant that he could have a number of infections affecting his brain, and Gonja doesn’t have the diagnostics to determine which organism is most likely. Instead of diagnosing, apply the shotgun approach – the patient got antifungals, antibiotics, and of course was restarted on antiretrovirals!
The topic that merges HIV and OB is Preventing Mother To Child Transmission (PMTCT). They are very careful about checking a new OB’s HIV status, even requiring both husband and wife to come to the first OB visit together so that both partners can be screened. The charts have a number designation written on them to communicate the HIV status. If the result is not known, the woman is PMTCT 0. If the result is positive, she is PMTCT 1, meaning she has HIV and needs to receive ARV therapy. If the result is negative, the woman is PMTCT 2. There have been a few PMTCT 1 deliveries, but Kendra and I always missed them because they happened in the night or they didn’t tell us they were going to C-section. However, we did see that they are careful to document delivery of the correct medication to both mother and baby to prevent transmission.
Friday, February 15, 2013
Tanzania Part 2
Hello All!
I forgot to mention one aspect of the set-up here that is fairly important. In addition to the staff here, the hospital is currently hosting 10 Tanzanian students from Kilimanjaro Christian Medical University College. They arrived a few weeks before we got here, and will leave one week before we do. They are third year students, having their first clinical experiences. As part of their training, a resident comes from Kilimanjaro Christian Medical Center (KCMC) to teach them for a week in their specific discipline. They had OB/Gyn before we arrived, a pediatrics resident last week, and this week is a resident in internal medicine. I really like having the university-minded resident here – it allows me to see how the healthcare services provided are different even within this country because going on rounds with the resident is a different experience from rounds with the Gonja doctors. For example, he clarifies to the students that although the young woman likely does have somatization disorder, ideally we should check for organic causes of her behavior and the diagnosis of somatization disorder is one of exclusion. Another example is a type I diabetes mellitus patient that was admitted before Kendra and I arrived and is still here. The first day the resident saw him on rounds, he asked if they could do labs to check for end organ damage from the disease – how are his kidneys? His eyes? These things were not considered by the providers here – or at least not mentioned to me. Perhaps they didn’t mention it because they know they cannot carry it out. Which brings up the issue of resources.
One resource is doctors. When we talked on Tuesday, the resident described a familiar problem – doctors (especially specialists) finish their training and want to stay in the big cities. Even young adults who grew up in a rural area, once they go to a big city for training and get used to living there, do not want to return to the rural area they are from. Another resource is equipment, and I don’t think you will be surprised to hear that the hospital here lacks many diagnostic tools we take for granted at home. They have an x-ray and an ultrasound, but no CT. Also, I don’t think they have anyone here trained to use the ultrasound machine, which they need in order to really take advantage of what they can do with it. We went to the lab one day to learn what they can do here, and I still don’t think I know for sure. However, there are definitely blood tests that they cannot do here. As for treatment, we’ve had a number of patients that need one antibiotic, but can’t have it because it is out of stock. I am not sure they even stock other things, like dextrose solutions in higher concentrations than D5 (important for hypoglycemic patients), or small enough gauge IV’s for neonates. Of course, they do have medicines that I bet I couldn’t find in Clarion (mostly anti-retroviral medications for the HIV patients). Maybe it comes down to priorities and where they can spend money to benefit the most patients.
One last comment on resources; my friend and classmate had an experience with a patient in the hospital who had a terminal cancer and also a drug-resistant infection that was only susceptible to one antibiotic. When they ordered that antibiotic, it just so happened that they got a warning saying there is a (national?) shortage of the medicine. They went through the extra paperwork required and got the medicine for their patient. I heard about it because my friend brought up the ethics of using a limited resource for a patient that is going to die no matter what. In this case, the hospital/state/country is so big that the physicians treating the terminal patient will not actually feel the shortage or have to compromise care of another patient. At Gonja Lutheran Hospital, however, it is a different story. Choosing to treat an HIV patient with an opportunistic infection that they likely won’t be able to fight off might take antibiotics away from an infant later. Just a thought.
Probably I thought about this scenario because in our first week here there was a 5 day old baby boy who died of septic shock due to cord sepsis. The pediatrician from KCMC was here that week, and he had initially written for ampicillin and gentamicin to cover the possible organisms. The hospital didn’t have either of these, and instead they started injections of ceftriaxone. The baby got 1 or 2 days of antibiotics, but didn’t make it.
Just 2 days after that baby died, Kendra and I attended a delivery of a baby girl. She was born around 11:00 am and looked terrible. She didn’t cry and was blue and limp. I grabbed the bulb suction and tried to clear any secretions, but she still wasn’t breathing. Every once and awhile her mouth opened and closed in a way that reminded me of a fish out of water. There are many details to the resuscitation that I won’t describe because I’m not sure I can do it accurately. Mostly, the resuscitation was slow to be initiated and lacked many of the tools needed to do it correctly. Also, when it became clear she was having more prolonged trouble that stimulation and suctioning wouldn’t cure, Kendra and I had to really push to order diagnostic labs. Really, all we got was a glucometer that showed her to be hypoglycemic (this was about 2 hours after she was born). Although we were trying to get her to nurse at this point, mother and baby weren’t connecting. We ended up giving the baby 15ml’s of D5 solution (remember, D5 is the highest concentration they have) and we gave it orally because the smallest IV catheter they have is 24 gauge. Luckily, later that afternoon the baby started nursing. She stayed at the hospital for 5 days or so to receive antibiotics in case an infection was the cause of her hypoglycemia. There were a lot of things that could have gone differently, but maybe we wouldn’t have had to fight with her so much to start breathing if we had known we needed to correct her hypoglycemia and done that earlier.
Baby Girl (I can’t remember what they named her) has had the biggest impact on us so far. It plays right into Kendra’s project as well, as she was hoping to do some teaching about newborn resuscitation for her global health project.
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| the KCMC students packed up and ready to go home |
One resource is doctors. When we talked on Tuesday, the resident described a familiar problem – doctors (especially specialists) finish their training and want to stay in the big cities. Even young adults who grew up in a rural area, once they go to a big city for training and get used to living there, do not want to return to the rural area they are from. Another resource is equipment, and I don’t think you will be surprised to hear that the hospital here lacks many diagnostic tools we take for granted at home. They have an x-ray and an ultrasound, but no CT. Also, I don’t think they have anyone here trained to use the ultrasound machine, which they need in order to really take advantage of what they can do with it. We went to the lab one day to learn what they can do here, and I still don’t think I know for sure. However, there are definitely blood tests that they cannot do here. As for treatment, we’ve had a number of patients that need one antibiotic, but can’t have it because it is out of stock. I am not sure they even stock other things, like dextrose solutions in higher concentrations than D5 (important for hypoglycemic patients), or small enough gauge IV’s for neonates. Of course, they do have medicines that I bet I couldn’t find in Clarion (mostly anti-retroviral medications for the HIV patients). Maybe it comes down to priorities and where they can spend money to benefit the most patients.
One last comment on resources; my friend and classmate had an experience with a patient in the hospital who had a terminal cancer and also a drug-resistant infection that was only susceptible to one antibiotic. When they ordered that antibiotic, it just so happened that they got a warning saying there is a (national?) shortage of the medicine. They went through the extra paperwork required and got the medicine for their patient. I heard about it because my friend brought up the ethics of using a limited resource for a patient that is going to die no matter what. In this case, the hospital/state/country is so big that the physicians treating the terminal patient will not actually feel the shortage or have to compromise care of another patient. At Gonja Lutheran Hospital, however, it is a different story. Choosing to treat an HIV patient with an opportunistic infection that they likely won’t be able to fight off might take antibiotics away from an infant later. Just a thought.
Probably I thought about this scenario because in our first week here there was a 5 day old baby boy who died of septic shock due to cord sepsis. The pediatrician from KCMC was here that week, and he had initially written for ampicillin and gentamicin to cover the possible organisms. The hospital didn’t have either of these, and instead they started injections of ceftriaxone. The baby got 1 or 2 days of antibiotics, but didn’t make it.
Just 2 days after that baby died, Kendra and I attended a delivery of a baby girl. She was born around 11:00 am and looked terrible. She didn’t cry and was blue and limp. I grabbed the bulb suction and tried to clear any secretions, but she still wasn’t breathing. Every once and awhile her mouth opened and closed in a way that reminded me of a fish out of water. There are many details to the resuscitation that I won’t describe because I’m not sure I can do it accurately. Mostly, the resuscitation was slow to be initiated and lacked many of the tools needed to do it correctly. Also, when it became clear she was having more prolonged trouble that stimulation and suctioning wouldn’t cure, Kendra and I had to really push to order diagnostic labs. Really, all we got was a glucometer that showed her to be hypoglycemic (this was about 2 hours after she was born). Although we were trying to get her to nurse at this point, mother and baby weren’t connecting. We ended up giving the baby 15ml’s of D5 solution (remember, D5 is the highest concentration they have) and we gave it orally because the smallest IV catheter they have is 24 gauge. Luckily, later that afternoon the baby started nursing. She stayed at the hospital for 5 days or so to receive antibiotics in case an infection was the cause of her hypoglycemia. There were a lot of things that could have gone differently, but maybe we wouldn’t have had to fight with her so much to start breathing if we had known we needed to correct her hypoglycemia and done that earlier.
Baby Girl (I can’t remember what they named her) has had the biggest impact on us so far. It plays right into Kendra’s project as well, as she was hoping to do some teaching about newborn resuscitation for her global health project.
Wednesday, February 13, 2013
Tanzania
Hello from Gonja Lutheran Hospital, Tanzania!
Kendra and I arrived here a week ago, on Tuesday, February 5th after traveling for two days. We felt very welcomed by the people here and were immediately shown around the hospital by Sister Dora, the matron of the hospital. The hospital is built on two floors, and each floor is divided into North and South sides. The doctors’ offices are all located on the first floor, (south side) and this is where the outpatient department is conducted. There are four doctors total, and they take turns being the doctor on call and taking days off. As far as I can tell, the doctor on call has to round on the inpatients in the morning, okay admissions to the hospital, and be available for deliveries and surgeries. There are four doctors, Dr. Lusingu, Dr. Amini, Dr. Yona, and Dr. Mary – and even though everyone calls them doctors, they are technically Assistant Medical Officers. Our first week, Dr. Amini was on call. He is very expressive/animated and seems to have good rapport with his patients. This week, Dr. Lusingu is on call and Dr. Amini is gone to do things in town (down the mountain).
The other half of the first floor (the north side) is where the delivery room, main OR, and minor OR are located. So far, I have not seen a surgery, but we did have two very unique experiences in the delivery room that hopefully I can write about later. The minor OR is more like a procedure room and is used for things like ultrasound, setting a fracture, or proctoscopoy.
Upstairs is mostly inpatient. The south side of the upstairs is all wards. They are divided into male and female wards, and they group pediatric patients together but there hasn’t been enough for them to have their own ward. The nurse tells us during morning report there are somewhere between 30 and 40 patients in house, including the 7 women on “antenatal” who are really just waiting to deliver their babies. They are all have big bellies and share a room with beds like a ward, but it is on the north side and it is more colorful because they use their own brightly printed sheets. Also on the north side, second floor, there is the CTC where they have clinic for HIV patients on Thursday and the Maternal Child Health clinic, where they see well children under five and women for family planning and prenatal visits. The MCH clinic is open every day except for Wednesday when they go to do outreach clinics. The nurses at the MCH clinic also offer patient requested HIV testing/counseling and they said they see 3 or 4 people every day who are worried about having HIV – usually teenagers/young adults.
Our house is across the road and a little bit up the hill from the hospital. It is one building with two houses. The other half of the house is occupied by Dr. Lusingu and his family. I think Dr. Lusingu is the doctor in charge of Gonja. In our half of the house, there are three rooms. Kendra and I share one room, and the other room will be occupied by 2 DMU students on February 18th. The third room belongs to an employee of Gonja who is frequently gone, traveling for work. The house is neat and well kept, though not bug proof. We are currently scheming about how to solve an ant problem that has developed next to our front door. The ants have built a sort of highway from the corner of the “picture window,” down and across the wall, to the corner of our door. We also have lots of little lizard housemates and a constant stream of moth friends coming in to hang out and bounce off the walls (or our faces).
There is running water in the bathroom, but we can’t figure out how to make it run into the toilet tank. Therefore, we fill a bucket from the sink to flush the toilet. The sink and shower have cold water only. I hoped I wouldn’t mind, but it is hard to get under that cold shower. Lucky for me, Kendra hasn’t complained when I decide to forgo the shower for an extra day.
More than the cold shower, my biggest frustration with the house is that I am sleeping in a queen bed and the mosquito net won’t fit all the way around the mattress. It is a nightly struggle to arrange the net, and I still end up with it only over half of my body (so you can imagine how good the seal is).
That is a brief sketch of the layout here. We have had a few interesting patients that I can tell you about later, or maybe I’ll tell you about new patients I see this week!
Thursday, February 7, 2013
Tallinn Time
I spent yesterday in the capital of Estonia - Tallinn. The town is known for its Old Town which is, you guessed it, old. There are buildings dating back to at least the 13th century. It's also not very big, which makes it great for a one day adventure.
After breakfast at a locally famous pancake house, I went with others from all over the world on a free guided tour of the Old Town. In our small group, there were people from the UK, Spain, Moldova, Argentina, Russia, and myself. The tour was nice because the guide was able to explain a good bit of Estonia's complex history (which is essentially a revolving door of occupiers from the 1200's on, including Germany, Russia, Sweden, Denmark, and a Polish-Lithuanian kingdom.) Only for a handful of years have the Estonian people really controlled their own destiny.
How about a brief history of Estonia? It's quite fascinating to me because I knew next to nothing of Estonia's history (or of Scandanavia for that matter). There are several major wars that I was completely unaware of. Anyway, the documented portion of Estonia's history started when German crusaders invaded the territory in the first decade of the 1200's. Around a decade later, Danish crusaders attacked from the North at what is present day Tallinn.
There was a major Estonian uprising in the mid 1300s, the Danish were forced out in the 1300s, and there was a Russian attack in the 1400's, but from the time of the crusades to the early 1500's, German nobles of one order or another held the majority of power and wealth in Estonia. Indigenous Estonians were treated as serfs (at best) during this period. The next stage is way more complicated, but the gist of it is that there were significant internal rivalries between different nobles and religious leaders holding the power in Estonia and the territory had very complicated relationships with surrounding Kingdoms as well. What seems to have been a tense peace fell apart in 1558 at the beginning of the Livonian War. Russians (led by Ivan the Terrible) invaded present day Estonia and fought, over the next 25 years, with varying combinations of the Kingdom of Sweden, a Polish-Lithuanian Kingdom, and the Danish/Norwegians. The Estonians themselves remained relatively subservient to whichever army was occupying the territory. The best they were able to do seems to have been to pull for the least offensive occupier, which was the Swedes. The Polish-Lithuanian Empire and the Swedes fought in the early 1600s after the Russians had enough and Estonians were treated rather well under the rule of the Swedish people.
And it goes on and on...the Russians fought the Swedish again in the Great Northern War of the early 1700s and won Estonia back. The Russians retained control over Estonia until the early 1900s with significant German influence. In 1918, they gained an independence (though the Soviet Union seems to have continued to be a significant influence even then, despite the wishes of the Estonians) that lasted for 22 years. In 1939, the Germans and Soviets signed a secret pact to essentially divide up the countries between them. Estonia tried to remain neutral in the war, but the Soviets threatened to invade if they didn't accept military bases and troops on Estonian territory (solely for the Estonians protection of course). Thus Estonian became occupied once again. In 1940, the Soviets left their military bases and formally took over the country, forming the Estonian Socialist Soviet Republic, which was never formally recognized by most of the Western world. The U.S. kept communicating with a true Estonian government that had no power. For a time, the Germans advanced and took control of Estonia, but were eventually pushed pack and Estonia remained rather forcefully controlled by the Soviets until the late 1980's and early 90's when Estonia gradually and incredibly, without violence, gained their independence.
In an interesting side-note of history, Estonians, Lithuanians, and Latvians formed a 360 mile long line through the three countries, joined hand to hand and singing as a protest of Soviet occupation of their countries. You read that right, 360 miles. Wow.
That's probably the most interesting part, but a quick run through of the day after the tour...a couple Moldovans from the tour and I went to this little medieval themed cafe in the bottom of the town hall. A sassy woman served us pastry pies and elk soup. She warned us that we should remember to bring our own "weapons" next time. You know, swords and silverware. It was good, but mostly I was glad it was warm. Afterwards we walked through an old Soviet style market that had a reputation for being a very shady place in its day. We continued on to see an old Soviet prison. We only got to see the outside, but the inside is supposed to be pretty dreary. It remained open all the way until 2005.
The final part of the day was a visit to Estonia's maritime museum, Seaplane Harbour. It's a very modern museum with diverse descriptions of maritime history from iceboats, to buoy styles through the years, to submarines and coastal defense. The highlight is a WWII era Estonian submarine that you can look through. There was also an icebreaker in the harbor available to walk through. The giant steam engines buried deep in the hull were pretty cool. Unfortunately, I have no pictures, because the batteries on my phone died at the prison. Too bad. The rest of the night was low key back at the hostel and I got up early in the morning to catch the ferry back to Finland, where I went to visit a 250 year old island fortress called Suomenlinna. I'm staying in a hostel on the island at the moment. More about Helsinki later!
How about a brief history of Estonia? It's quite fascinating to me because I knew next to nothing of Estonia's history (or of Scandanavia for that matter). There are several major wars that I was completely unaware of. Anyway, the documented portion of Estonia's history started when German crusaders invaded the territory in the first decade of the 1200's. Around a decade later, Danish crusaders attacked from the North at what is present day Tallinn.
There was a major Estonian uprising in the mid 1300s, the Danish were forced out in the 1300s, and there was a Russian attack in the 1400's, but from the time of the crusades to the early 1500's, German nobles of one order or another held the majority of power and wealth in Estonia. Indigenous Estonians were treated as serfs (at best) during this period. The next stage is way more complicated, but the gist of it is that there were significant internal rivalries between different nobles and religious leaders holding the power in Estonia and the territory had very complicated relationships with surrounding Kingdoms as well. What seems to have been a tense peace fell apart in 1558 at the beginning of the Livonian War. Russians (led by Ivan the Terrible) invaded present day Estonia and fought, over the next 25 years, with varying combinations of the Kingdom of Sweden, a Polish-Lithuanian Kingdom, and the Danish/Norwegians. The Estonians themselves remained relatively subservient to whichever army was occupying the territory. The best they were able to do seems to have been to pull for the least offensive occupier, which was the Swedes. The Polish-Lithuanian Empire and the Swedes fought in the early 1600s after the Russians had enough and Estonians were treated rather well under the rule of the Swedish people.
And it goes on and on...the Russians fought the Swedish again in the Great Northern War of the early 1700s and won Estonia back. The Russians retained control over Estonia until the early 1900s with significant German influence. In 1918, they gained an independence (though the Soviet Union seems to have continued to be a significant influence even then, despite the wishes of the Estonians) that lasted for 22 years. In 1939, the Germans and Soviets signed a secret pact to essentially divide up the countries between them. Estonia tried to remain neutral in the war, but the Soviets threatened to invade if they didn't accept military bases and troops on Estonian territory (solely for the Estonians protection of course). Thus Estonian became occupied once again. In 1940, the Soviets left their military bases and formally took over the country, forming the Estonian Socialist Soviet Republic, which was never formally recognized by most of the Western world. The U.S. kept communicating with a true Estonian government that had no power. For a time, the Germans advanced and took control of Estonia, but were eventually pushed pack and Estonia remained rather forcefully controlled by the Soviets until the late 1980's and early 90's when Estonia gradually and incredibly, without violence, gained their independence.
In an interesting side-note of history, Estonians, Lithuanians, and Latvians formed a 360 mile long line through the three countries, joined hand to hand and singing as a protest of Soviet occupation of their countries. You read that right, 360 miles. Wow.
That's probably the most interesting part, but a quick run through of the day after the tour...a couple Moldovans from the tour and I went to this little medieval themed cafe in the bottom of the town hall. A sassy woman served us pastry pies and elk soup. She warned us that we should remember to bring our own "weapons" next time. You know, swords and silverware. It was good, but mostly I was glad it was warm. Afterwards we walked through an old Soviet style market that had a reputation for being a very shady place in its day. We continued on to see an old Soviet prison. We only got to see the outside, but the inside is supposed to be pretty dreary. It remained open all the way until 2005.
The final part of the day was a visit to Estonia's maritime museum, Seaplane Harbour. It's a very modern museum with diverse descriptions of maritime history from iceboats, to buoy styles through the years, to submarines and coastal defense. The highlight is a WWII era Estonian submarine that you can look through. There was also an icebreaker in the harbor available to walk through. The giant steam engines buried deep in the hull were pretty cool. Unfortunately, I have no pictures, because the batteries on my phone died at the prison. Too bad. The rest of the night was low key back at the hostel and I got up early in the morning to catch the ferry back to Finland, where I went to visit a 250 year old island fortress called Suomenlinna. I'm staying in a hostel on the island at the moment. More about Helsinki later!
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| Toompea Castle - Home of Estonia's parliament. Every ruler since the 1200's has used the castle as a seat of power. |
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| St. Nicholas' Church in Tallinn. Originally built in the 13th century, the vast majority of the church is now much newer because it had to be reconstructed after a Soviet bombing near the end of World War II. |
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| A section of the old defensive wall of Tallinn. Legend has it (apparently with some legitimate historical basis, though it probably didn't fall from heaven as the legend goes) that this is the site where Denmark's flag was first created. |
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| The Alexander Nevsky Cathedral across from the parliament building. Built by the Russians in the late 1800's, many Estonians despised the church as a sign of the forced occupation and "Russification" of Estonia. |
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| Old Soviet-style market near Old Tallinn. They say that you used to be able to buy AK-47s and passports here only a little more than a decade ago. The picture doesn't do it justice, but the "booths" are many small corrugated steel buildings. It definitely has a sort of ominous Soviet feel. |
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| View of the Old Town from the town wall. |
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| Tallinn's town square |
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| Former Soviet Prison, "Patarei." Along the coastline of Tallinn. |
Wednesday, February 6, 2013
European Beginnings
Back after a long hiatus...Andrea and I were much busier during our month studying Spanish in Riobamba and Andrea didn't have wifi in her house (clearly she's the real driver of the blog), but I'll add a little about the first few days in Scandinavia. Wishful thinking perhaps, but maybe I'll work on adding some details about the last month in Ecuador soon too...or you'll just have to find one of us to hear about that part.
I went to bed at 6 PM and slept till 4 AM when I had to get up to get to the airport and catch a 6:30 flight to Helsinki, Finland. Really I spent most of the day traveling, as I also took a 2 hour ferry ride across the Baltic Sea to Estonia. In between the flight and ferry, I asked one of the workers at the ticket booth for a good local restaurant and went and found myself a Finnish buffet in a cozy little place. The coziness was welcome, as it was cold, windy, and snowing outside. The ferry was huge and quite comfortable. It had 9 floors, which included a 3 level bar with giant windows in front of the ship. It also has its own "mall," and dozens of cabins. Not to mention the semis that it hides away in its belly. All in all, it was an uneventful trip and I found my way to my hostel in the Old Town of Tallinn, Estonia easily. It turned out to be a little wilder hospital than I'd prefer, but the 3 very drunk Englishmen and 1 Australian kept it from being boring.
I arrived in Europe this past Sunday afternoon when I landed in Copenhagen. Then it was a quick flight to Stockholm, finding a hostel for the evening, and hunting down a grocery for some supper, all of which were quite easy. One of the first things I was struck by in Stockholm is that everyone speaks English, but you'd never know it if you didn't strike up conversations with folks. No one speaks anything but Swedish to each other, even though virtually everyone speaks English fluently. Everyone is very friendly and doesn't seem to mind speaking English, but I feel a wee bit of shame every time I make someone use it. No matter where I am, I always wish I could speak the local language.
That evening, I got a couple hours sleep and then, in good American fashion, woke up to watch the Super Bowl live online. Normally, I don't care so much, but the 49ers have been my favorite team since childhood. Tough loss...oh well...moving on. Maybe not quite yet...watching the Super Bowl by yourself at 4 in the morning in a place where no one else cares makes you realize it's not very important, but still rather fun. I was glad my body was still on U.S. time or I wouldn't have made it through the game.
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| Random street in Stockholm, not far from the Karolinska hospital where I'll be rotating in a couple weeks. |
The next day was spent getting things arranged for my stay in Stockholm. I bought a SIM card, so that I have phone and internet service here, rounded up some more Swedish Krona, and picked up the keys to my apartment. It's a small, but nice, place and the floor is filled with other international students. I don't remember all they told me, but there's a Spanish medical student, a South African doing research on diabetes (In Sweden? The obesity problem is so much less there that diabetes must be far less as well. It seemed like an unlikely place to go to study diabetes.), and a German girl studying public health. They were all very friendly and I look forward to getting to know them more.
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| Helsinki is significantly colder than Ecuador. |
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| The cozy little Finnish restaurant, near the West Harbor of Helsinki |
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| Finnish food. Lots of meat, potatoes, bread, and cabbage. |
That's enough for now. Today was much more interesting checking out sights around Tallinn, but I'd like to write a little about Estonia's complicated history and that will take more time than I have now!
Michael
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| This doesn't do justice to the size of the enormous ferry. |
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| Every ferry needs a 3 story bar, replete with giant windows and a live stage. |
Thursday, January 17, 2013
Quilotoa Loop 1/3-1/6
We got on the 9:00 bus on Friday morning from Latacunga to Zumbahua with what we thought we needed in Michael’s daypack and Andrea’s backpacking pack. We had plenty of time on the bus and sit and read the phrases written in Spanish on the walls. One said “Jesus es mi pastor nada me faltara” which we eventually figured out is quoting Psalm 23 – The Lord is my shepherd, I shall not want. Every bus trip has to have a part that is the most interesting. This trip’s came when I pulled my backpack out from the storage underneath. I saw 3 chickens on the shelf next to it, sitting there like it was their coop. And just like if it was their coop, they’d laid an egg or two – which of course broke during the ride and my backpack got an egg bath. You can tell me if you think washing backpacks in eggs makes them nice and shiny when you see my pack next.
From Zumbahua we hitched a ride in a truck to Quilotoa. The driver dropped us off at the nicest hostel we’ve stayed at so far. Actually, I am going to go ahead and say it was a hotel. We got one room with two queen (or at least double) beds, just like an American hotel. It had it’s own bathroom, just like an American hotel. How was it different? We had a wood stove to heat the room. The sink had one knob with cold water only. The shower was bipolar as far as heat and even water pressure goes – up and down without ever touching the knobs. I won’t complain too much because there could have been no hot water at all.
The sky cleared some and we decided to hike down to the water’s edge. The incline was very steep, and in many places the path was soft like sand on a beach. As we went down, we passed people coming up on the backs of donkeys. There were only a few people “hoofing it” with their own two feet, and they were sweating and breathless. I soon learned how they felt
At the water’s edge, there was a
little beach and a hill cropping up next to the beach. It would have been fun to
explore all the little trails in the area, but Michael didn’t want to hang out too
long incase it started raining on his non-rain coat. Therefore, we put our
hand in the water (it wasn’t warm, but it wasn’t as cold as we thought it might
be) and started the hike back up.
I got tired on the gentler section
closer to the beach and was worried Michael would run away from me. I shouldn’t
have worried. He was very patient and gave my back a little push a few times.
The guidebook said it would take about an hour to climb back up to the rim of
the crater, but we got up in closer to 35 minutes. I’d like to say that Michael
was pushing us so fast because he was afraid of rain, but I think that if it
had been sunny we would have gone the same speed.
After our hike we settled into the common room at the hotel. I drank lots of tea with hot water heated on top of the wood stove and talked with the other
guests. There was a group of nine Dutch on a mountain bike trip, a couple
living in Canada (the girl was from Germany originally), and a younger couple studying at the
University of Illinois who were visiting the guy’s family in Ecuador. We really
enjoyed the company!
The next day we hired a guide to hike from Quilotoa to Chugchilan. Actually, we hired the guide's son, but then things got switched right before we left. He was trying to explain to us, but it was in Spanish so I'm not sure we really understood. He told us something like his mom had more experience than him, and maybe that she needed to go that way anyway. At first I thought she was just walking with the three of us, but then she led the way and he turned back to Quilotoa. Well...OK!!
We set out at about 9:30 in the morning from the lake. The first part of the hike is along the crater rim, but we soon started making the descent down. Overall, we went down in elevation from Quilotoa to Chugchilan. However, there was a fair amount of climbing up out of valleys too. When we first started, I thought that Chugchilan was just on the other side of the first valley. That was not correct at all. In fact, we couldn't see our destination until halfway through the trek. In the picture of Michael to the left, you can see the hill he is standing on, the hill behind him, and the hill to the left of his head. The hill to the left is the one that we came down from the crater rim. You can't see the bottom of the valley where there is a stream that we crossed. We started out with all our coats on, but you can see that after that first scramble up from the stream bed, Michael is down to his long-sleeved undershirts. It ended up being a beautiful day, and maybe even a little too much sun. Probably between 10 and 11 we got out our sunscreen. As we were applying, the guide asked if she could use some too. Of course we offered her the bottle. Later, we also offered her some water from our bottle and the water bladder in the backpack. It was fun to try and communicate how to use the bite valve for the bladder. 
Fairly early on, our guide broke off a branch from a bush near the path. She drug it along, and when we came up to some cows, she waved it at them to get them to move from the path. Later, she traded the branch with leaves for a stick about the size of a thin walking stick. This she used to point and shake at dogs that ran up to us barking and growling. We passed many small "farm" houses. It was interesting to see how they farmed any land they could, even land that had about a 60 degree grade to it. More often than not, the fields were more the size of our garden plots in Iowa. I wish I knew what they were growing. Michael also thought it was impressive how close to the edge of the canyon they planted. The picture without the cows shows the opposite edge of the canyon from where we walked and the fields on top going all the way to the edge. 
In addition to dogs, fields, and livestock (llamas, sheep, and cows were most common), we also saw people working in the fields and kids playing. Well, mostly we saw kids standing and staring at us as we walked past. The saddest thing we saw was a donkey on the side of the road. It was lying on its side and as we got closer it was evident that it was dead. There were three kids next to it, pushing on its large belly. At first I thought they were trying to wake it up, but as we passed them and I looked back, I decided they were trying to get the baby donkey out. It looked like there was something bulging from the donkey's rear end and our conclusion was that the poor burro had died because of stalled labor. 
The whole hike took us 3 hours, and we arrived at about 12:30 pm in Chugchilan. I think we really pushed the pace on this trek too, we were told it would be closer to 4 hours. Our little guide kept a pretty good pace for us until the last uphill into town. She had to pause quite frequently, and we were worried she hadn't had enough to drink. So, in addition to the $25 we owed her for her services, we gave her a 16 oz water bottle. The picture to the right is of the three of us at the hostal in Chugchilan. We covered 10+ kilometers and didn't do anything for the rest of the day. If you find yourself in Chugchilan, I would recommend the Hostal Cloud Forest. It was very nice and from what we heard from other travelers the other places in town weren't as good. :)
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