stories 4

Some patient encounters just stay with me.


I can still vividly remember the 40 y/o woman who casually told me as I took a sexual history during her annual gyn exam that she had been raped at age 8 and then became sexually active at age 14.  She had no idea what her lifetime number of sexual partners was because, as an addict, she sold sex for the drugs that enslave her.

Another day, I was following in a specialty clinic when we saw a 75 y/o woman with her husband and daughter.  It fell to the specialist to tell her that her brain cancer - despite surgery, radiation, and chemotherapy with all of their side effects - was spreading and that, without further treatment, her prognosis included decline in movements, sensation, and cognition.  I contemplated what it would be like to sit for a moment in her shoes - to face the knowledge that the rest of your life will be a journey of loss, whether slowly or quickly.

The statistics say that 1/4 women and 1/6 men will experience sexual assault during their lifetimes.  I've lost track of the number of women who've told me that their boyfriend or stepfather or husband raped or otherwise abused them.  I silently mourned the young woman who told me last month that she had returned to her abusive boyfriend, sure again that this time would be different.  Her physical exam included noting the scar on her shin from the last time they were together when he had kicked her.

My last inpatient month had one particularly heart-wrenching moment.  After a difficult family meeting discussing goals of care and life expectancy with the nearly-unresponsive patient and his Asian wife in the room and an English-speaking family member on the cell phone and a translator on the Cyraphone who could half-hear the goings-on, I was standing outside the room to write the note.  His wife, who cried silently during the family meeting but courageously accepted our predictions of outcome and made appropriate decisions in response, began sobbing disconsolately in the corner of the room.  How alone she must feel, I thought, wishing for her only family member to whom she could talk freely who was miles away, separated from health care providers by language, and isolated from her beloved by disability now and soon by loss.  Her helpless sobs still ring in my ears.

It is to this world that Jesus came as a baby 2,000 years ago as we remember this time of year.  A world where her acceptance of his birth could have cost his mother her life.  A world where his acceptance of God's call to take up all our sin and suffering did one day cost him his.  A world where, somehow, some way, I need to hang on to the fact that the cross is not the end of the story.  A world where - despite all appearances to the contrary - death and addiction and evil and shame and sorrow and loss do not have the final word (but instead resurrection does).  A world where because of the tear-streaked, oh-so-human face and blood-stained, wounded flesh of Christ we never have to face suffering alone.  My longing for his coming and making everything right in this season of Advent will one day be fulfilled because he did come, his first coming a down-payment on his final coming.

As Justin and Lindsey Holcomb wrote in a Christianity Today article several months ago about rape:

So now, to the pain of all of us, including those who have been raped or sexually assaulted, the gospel says, "You will be healed." To your shame, the gospel says, "You can now come to God in confidence." To your rejection, the gospel says, "You are accepted!" To your lostness, the gospel says, "You are found and I won't ever let you go." To your sin, the gospel says, "You are forgiven, and God declares you pure and righteous." To your death, the gospel says, "You were dead, but now you are alive."


May it be so.  I tell these stories to remember the people myself and to remind myself that God does not forget them. 

bonsai and horticulture

Stuart and I went to a bonsai class at the National Arboretum in DC for National Bonsai Day a couple weeks ago.  We weren't planning on this, but it was advertised on our visit to the Arboretum, and so we sort of walked into it.  I was impressed with how much the lessons from the bonsai cultivator who gave the lesson on bonsai mirrored things that are true of our lives with God as the master gardener who cultivates his vineyard (Isa. 5:1ff, 27:2ff; Eze. 19:10ff.; Hosea 10:1ff.), of which Jesus is the best example (John 15:1ff.).  I think we've lost much of the significance of the careful cultivation of growth, fruit, and natural beauty because we simply don't do it anymore.  I have a garden, and I still didn't know much of what he said that I thought was significant for insights for our lives.  So here they are. 

First, I loved what the speaker said about how he picks plants with which to make a bonsai, a specially cultivated and shaped miniature tree:  he looks for the ugliest ones.  He didn't explain why, precisely, at least not that I remember, but it was an encouragement to me as I thought of God molding our lives.  If our speaker can intentionally pick the ugly plants, surely God can use us with the brokenness we bring and can shape us over time into creatures of beauty and fruitfulness.


http://www.asktonythegardener.com/Article/tabid/55/smid/370/ArticleID/75/reftab/36/t/Bonsai-Plant-Art/Default.aspx

Time is another bonsai requirement.  Bonsai, the teacher explained, is a long-term practice, a development of beauty of form and structure that requires patience since every change can require months to "set" and long-term shaping requires years.  Families pass a tree down through generations since it can take that long to form it.  It is a never-ending process, and you can never simply leave the tree alone as a finished work of art.  Instead, as a living piece of art, it is constantly changing and growing and so requires ongoing molding and shaping.  I remember learning in Old Testament class in college that one of the benefits of the Old Testament is seeing the work of God over years and centuries with his chosen people.  Their recurrent failures, few luminous successes, and ongoing gradual transformation through the pages of the books of Law, Prophets, and Writings encourage me that God will be faithful to continue working in my own life and the lives of those around me.

Learning what leads to and inhibits growth was also interesting.  For instance, in the process of shaping the tree to a certain shape, you often cut off much of its foliage growth.  However, it is important to maintain at least the growth at the end of the branch since the branch will die if one cuts off all of its growth.  It makes me wonder what parts of my life I expect to maintain if I do not allow room and cultivation for them to grow and be fruitful - simple things like playing piano, or certain oft-neglected relationships, sometimes even more important things like my spiritual life, etc.  In a busy lifestyle, it is easy to forget the importance of maintaining growth and exposure to light and food for the important but sometimes not-so-urgent parts of my life.

Another growth principle involves encouraging ramification (branch formation) and fuller foliage pads through pruning.  If new growth is pinched off (e.g. removing the new bright green growth in the spring), it will allow the tree to funnel more energy back into its branches and remaining leaves.  For deciduous trees, sometimes defoliation is practiced (removing all the leaves) since reformed leaves are smaller and more numerous after defoliation.  For both evergreens and deciduous trees, new branches are formed, and the remaining foliage pads that have been pinched off grow in more fully. 


http://www.mybonsaibuddy.com/749px-Trident_Maple_bonsai_52,_October_10,_2008.jpg

Pruning is always something that makes me a bit nervous in gardening.  It requires cutting off something that looks like growth (e.g. a leggy stem of my petunias with flowers on the end) and trusting that more and fuller growth (e.g. more flowers closer to the plant and a fuller, more attractive result) will result from the loss.  In the same way in my own life, pruning takes courage.  It involves passing through pain, allowing God to take away something I thought was growth and flowers and trusting that he will cause different and more beautiful growth in its place.  It can mean redirecting energy into remaining branches and leaves when distractions are fewer.  It means trusting the as-yet-unseen.

A final aspect of growth involves growth that can be missed - that of the roots.  The overall picture and part of the beauty of a bonsai tree involves the roots.  They are considered in deciding how to shape the tree, and they grow when the tree seems most dead:  in the winter.  It is encouraging to me to think that the foundational strength of the tree, the ability to stand tall against storms and winds, the deep reaching for water, the stability and, well, rootedness of the tree actually grow when the tree looks dead.  As I look at my own life and the lives of those around me, where could growth be occurring under the surface where things look lifeless?  When we pass through periods of barrenness and cold and lack of fruit, can we trust God to be causing our roots to grow, actually to make us more stable in the very times when we feel least productive and secure?


http://mfs.piccsy.com/t/pall-bonsai-winter-156626-475-545.jpg

Besides organic growth, the bonsai maker/cultivator actually shapes the branches and directs where they will grow.  He does this by first wiring the branches, using flexible coated wire to wrap in spiral fashion the branches nearly from the extremity on one branch to the trunk and back out to the small distant parts of another branch.  Once all the branches are wrapped, he starts to shape them, moving them into the position he wants them from bends in the branches themselves to their overall direction so that foliage pads are placed in pleasing, balanced ways.  It reminds me of how God wants to be Lord of all of my life, shaping and forming and crafting all of it from major branches to smaller parts to be an overall picture of beauty and wholeness.

An interesting part of bonsai's idea of beauty is the idea of dead wood.  Part of the ideal of bonsai beauty is the idea of age, and the bonsai maker will cultivate bends in the branches and an overall downward, weighted-down droop to the branches of even a young bonsai tree to simulate age.  Another way to simulate age is through dead wood on the trunk (shari) and branches (jin) where the bark is literally torn away to leave dead wood and simulate the wearing experience of age in a young tree. 

In other words, the creator of bonsai actually intentionally makes scars to contribute to the beauty of the tree.  I don't think God necessarily wounds us intentionally, although pruning can feel like it; we probably create enough wounds of our own as we pass through life and fall into scrapes and pits we could have avoided if we had listened.  But the idea that the scars can be part of the beauty is intriguing.  Do we lament our wounds instead of offering them to God to be formed into part of the work he is making?  Do we try to cover scars that could be used to nourish others' healing as they see how the scars form part of the beauty in us?  Do we really trust - in pain or in plenty - that God knows what he is doing in us?

http://artofbonsai.org/galleries/images/stemberger/small/stemberger_juniperus_procumbens.jpg

The final insight I gathered about bonsai making is that the artist shows through in the art.  Some bonsai are crafted to look windswept and forlorn, evoking a favorite gnarled tree near the artist's usual hiking trail.  Others are upright and stately, reminiscent of a childhood tree that perhaps housed a swing or treehouse.  No matter the story behind it, the artist's own person shows up in some way in the art.  And that is the goal of God's working in us as well:  that we would reflect his image.  The reason God got so riled up in the Old Testament about idols was that they showed how completely Israel had missed the point:  instead of being the image of God, the reflection of his character and glory to those around them, they were worshipping images of wood and stone.  What further purpose could we want but to reflect back the shining grace, strong justice, and tender mercy of our Father?  As we come to know him, we will grow in love of him, and we will grow more like the One we love.  This is what it means to be a tree "planted by streams of water, which yields its fruit in season and whose leaf does not wither" (Ps. 1:3).



http://en.wikipedia.org/wiki/Bonsai


Of note, Stuart will have a lot more time to continue learning these and other lessons.  There was a raffle at the end of the bonsai class.  He won the demonstration bonsai.  :)

reflections

written 5/6/12 on the train on the way back from the airport

After 17 hours en route, I arrived back to Lancaster today.  I did my best to say my despedidas (farewells) well as I left.  Before I start a busy month on OB tomorrow, I wanted to try to process some of the rotation today.  

  

Ecuador, at least the parts I experienced, is much better off economically than either the majority of India or Zambia, my two most recent overseas points of comparison.  It shows up in little things, like the fact that having dogs as pets is common (no one can afford to feed a dog regularly where I was in Zambia when their kids come into the hospital with severe malnutrition).  Fashion in Ecuador goes beyond the usual more-dressed-up-than-your-average-American lack of cotton (usual in Latin America in my experience) and tight jeans, reflecting more the fashion mores – the little I know them – of North America and Europe with scarves, boots, and cute handbags.   The life expectancy is high, and I did see some diseases of affluence (e.g. diabetes), even if their management is more difficult (no glucometers, no lancets, etc.)

It makes me wonder if I would be needed there, medically at least.  I respect the doctors who work there, many of whom have given years of their lives to serve far from their culture of origin, families, and same-culture friends.  Their sacrifice to be obedient to God's call on them is not to be ignored or easily dismissed. 

Still, my experience also made me think about the style of missions I want to be part of.  Due in part to the need to be close to the hospital, in part to regulations requiring them to clearly demarcate the HCJB lands, and in part to security concerns, the vast majority of the missionaries from various organizations live together on a fenced in compound behind the hospital with a gate that closes and locks at night.  Most of their kids go to a missionary kid (MK) school where Spanish is taught as a language. 

I’m ambivalent about these things.  When I’m on call at night, I like the security of knowing there’s a locked gate when I walk home at one or two in the morning.  I like the fact that the walk takes me two minutes and not ten (and that would be dangerous for patient care in some situations if I couldn’t get to the hospital quickly enough).  But I don’t like the sectarian feel of living in a separated-off part of town (“Gringolandia,” as the residents called it, and even they didn’t "trespass" there) rather than with the people whom I came to serve.  

Jesus came and tabernacled among us (John 1), walking in our dust, eating our food, suffering our vulnerability in service.  If he is my model, to what extent can and should I avoid the daily complications and risks of life overseas if it lies within my power?  Eating from vendors off the street?  Risking getting a few GI bugs and parasites in order to eat with people in their homes, including vegetables and fruit that weren’t soaked in special cleaning solution?  Risking being a target of robberies or worse if I live among people as someone who is noticeably different?  How would this look with a family?  To what extent could I expose my children – Lord willing – to risks I undertake to serve him and his people?

I’m also ambivalent about the schooling.  Part of me thinks that an MK school right next door to the hospital would be attractive – a quality school where one’s children could attend in their native language without having to be far away (i.e. like the old boarding school model where one’s children were sent off starting at age five and saw their parents in the summers).  But part of me wonders what message it sends the community about my opinion of the quality of their schools, the desire (or lack thereof) for our children to be friends with their children, and the importance of language and culture learning in the nearly effortless, osmotic way that only children can learn them.   

I envision children being such a potential benefit for building relationships and bridges when in a new cultural context and for modeling in a marriage and a family what effects Jesus has on our lives.  What would it mean to do what is best for them and also avoid setting up additional barriers between me and the national people?  This is especially complicated with older children (how different can it be to learn to add and subtract, read and write in another language as long as they use the same letters and numbers? but what if they didn’t?) and when I’m not sure about coming back to the States for the children’s schooling later, meaning they would have to be able to fit back into our educational system and learning in English.

A photo of a painting by famous Ecuadorian painter Guayasamin, who broke expectations by portraying his subjects with the blunter fingers and facial planes of the indigenous people.  Ecuador does still suffer controversy regarding discrimination against its indigenous population.

These questions aside, there are many ways in which working in a place like Hospital Vozandes del Oriente would be much easier and simpler than working in many other places I have been.  Many more lab tests and even imaging studies are available, if not at our hospital then in Quito (e.g. Pap smears, TSH) or in nearby Puyo (e.g. CT scans).  As mentioned in other posts, living and working conditions themselves are relatively easy (e.g. electricity, running water, even hot water, washer/dryer).  I would enjoy working with residents and interns, and I LOVE speaking Spanish regularly.  It certainly is a spiritually open culture where I can speak of God and people generally understand what I’m talking about and are open to hearing it.  But I still don’t know…

Underlying all these questions is the bigger question of calling.  It is not so much a question of a calling overseas itself.  I’ve heard God’s voice on that enough times to trust that he wants me somewhere for some length of time at some point in the future.  But I still don’t know where or in what sort of context, and I’m nearing a point where I may have to make some decisions as I have one year of residency left. 

In general, I do have some personal sense of the importance of serving the poor as part of what it means to be working with God to bear witness to and bring about characteristics of his Kingdom.  But does that mean a certain percentage of my patients should suffer from the diseases of poverty?  Or that I should have to live a certain standard of living to really serve the poor?  Does that mean that most of my patients would die if I weren’t there, or is that simply me wanting to feel necessary and affirmed in my work?  If I were in a situation like Zambia where there is tremendous need and simply not the resources (people- or finance-wise) to meet it, would I still have the time in my schedule and energy in my life to reach out to people’s spiritual needs, or would I be so stretched thin and overworked that all I wanted to do was go home and sleep at the end of the day?  What would that sort of life look like with a family? 

Clearly a lot of prayer and discernment is still needed in my life over the next year(s).  I think a few good books on different styles of missions might be helpful.  I hope to continue talking with both the missionary contacts I have made and with mentors and friends in the States as I walk through this process.  God has been faithful to guide me clearly in each of my major life decisions to date (college, seminary, medical school, residency), and I can choose to trust that he will continue to do so.  In the meantime, I can also look for ways to learn more medically and missiologically, seek to do my best at working cross-culturally in a sensitive fashion with patient encounters that I have, and grow in loving God and allowing his love to overflow in me to others around me so that I can offer the life-transforming power of His grace to the needs that modern medicine 

trip to Quito

My final weekend in Quito was a great time of reconnecting with some of the first group of residents/interns and doing some touristy stuff with them before I left.  I had a wonderful dinner with Marita and her family, Anita and her brother Fernando, and Gaby and her husband and son on Friday night in a beautiful part of the downtown called the Ronda.  It is in a neighborhood of restaurants and shops in the old colonial style buildings with flowerpots everywhere and live music in many of the restaurants, including ours. 

Anita graciously hosted me despite having to work at 5 am on Saturday, and her parents fed me breakfast in the morning (after meeting me for the first time since we had gotten in around 1:30 am after a late dinner the night before.  Then I headed out with Gaby and her husband Luis (and later her son Gabriel and her parents, sister, and grandmother) to La Mitad del Mundo, the traditional (although slightly off) site of the equator in Ecuador. 

I loved the afternoon festivities of group after group of various folk dances from different parts of the country.  They included different brightly colored outfits and everyone seemed to enjoy watching, including the mostly Ecuadorian audience.  I got a little more involved in the enjoyment than I planned when one of the dancers hauled me into the dance at the end when they went around trying to get other people to join them!

 

This dance was from Esmeraldas, a mostly Afro-Ecuadorian province in the north.

 

 

A good reminder of how much dancing is a part of Latin culture for old and young alike.  These little girls and their little boy partners enjoyed the dance and participated just as much as the older dancers!

At lunch afterwards with Gaby's family, I even got to try cuy, or guinea pig, an Ecuadorian specialty. 

After the lovely day, we met up with Anita who had finished work and went to the artisanry market in Quito, where I got some earrings for my sisters.  Then I returned to Anita's house and hung out with her family until it was time for me to go to the airport.  I was blessed and touched by the hospitality of my friends, despite our short acquaintance.  They welcomed me into their families and homes and lives with no self-consciousness and no hint of the effort and time that hosting me cost them.  I am grateful for the grace they showed me.  It was a wonderful ending to my time in Ecuador.

viaje a Baños (trip to Baños)

The past two weekends I have gone to nearby Baños on my free weekends.  It is an hour plus trip on windy mountain roads, happily reinforced by guardrails and two-lane the whole way, although drivers do still pass on the road (but not on corners nearly as much as I expected).  It is a lovely trip through the unending green of the mountains with clouds visible hanging at an almost-touchable distance just above one's head.  Here are some of my pictures with narrative. 

This is from the first weekend trip with some residents with me trying to capture the way the wispy clouds hang on the mountainsides.

 

Landslides, or derrumbes, are always an issue in the mountains, although much less so with this road than the old one.  I think this was actually blasted away for the road, based on the marks in the dirt, but it reminded me of the possibility, especially with as much rain as they get here. 

Baños is known for its Virgen de Agua Santa, and there is a large and beautiful church whose walls are covered with paintings of stories where the Virgen saved people falling from bridges or whose house should have burned or during one of the volcanic eruptions.  This is the waterfall that overlooks the town.

Marking its location as a tourist hot spot, the busy bus depot is surrounded by many stalls of fruit and caña (sugar cane).

 

The lovely green mountains sweep into deep valleys invariably with a river at the bottom.

  

This is the plateau on which Baños is situated, overlooked by the Volcano Tunguraha, whose activity causes the hot springs and baths that give the city its name and parts of its attraction.  If you look closely, there are two small waterfalls on the right falling off the plateau.

It's just beautiful.

One of the many fruit and candy (taffy) stalls, complete with stacks of caña.  I managed also accidentally to get the typically dressed indigenous older man in the picture, which made me very happy.

Ha.  Pork, anyone?

A typical view of the mountains surrounding Baños' plateau.

The mountains in the background, the large church to the Virgen in the mid ground, and gorgeous bougainvillea in the foreground.

A map of Baños' plateau and the roads in and out and the volcano that overlooks it.  The windy road to the top left of the map goes up to Shell, second-to-last destination on the map.

The volcano itself.

One of the cascadas (waterfalls) on the Ruta de las Cascadas.  This one is called the Novios (boyfriend/girlfriend).  It used to be one falls alone, the one on the right and was called Manto de la Novia (the bride's veil), but after a volcanic eruption, the river divided higher up, and now the left one has been added to make the pair.

I think this one shares a name with the large dam and hydroelectric power plant, Agoyán.  I'm not sure which got named first...

We took a little cable car over to close to the falls.  I was glad I'm not acrophobic!

This little guy is called something related to snakes, I think Cascada de Culebra.

A view of the old road, which the older missionary doctor I was traveling with told me used to be open once a week due to landslides and muddy conditions.  It wasn't paved when he started here, and it drops off steeply to the right.  It didn't use to have that guard thing, either, and it was two-way, one-and-a-half lanes.  The road passes under a little waterfall off the rocks, which the doctor told me they used to call the carwash.  :)

This is one of later falls on the Ruta called Pailón del Diablo, or the Devil's Bowl-whirlpool, for the way the water crashes into that rock formation before flowing out at the bottom.

We caught the bus after a literally one-minute wait along the highway from the halfway point between Shell and Baños where the tour dropped us off and arrived back in Shell to a lovely sunset.  I just don't tire of the mountains here, so different from at home.  I do wish the clouds cleared up a bit more and I could see the stars (I think I could see both the Southern Cross and the Big Dipper the one night it was clear), but it makes for some lovely views.

food (that is, fruit)

Ecuador has several foods for which it is known.  Guinea pig, or cuy, is one, but I haven't tried that one yet.  It isn't as common here in the Oriente (eastern part of the country).  Mariscos, or seafood, are common on the costa (coast).  Some foods, such as bananas and sometimes strawberries and the Costa Rican fruit I knew as mamón chino, go by different names here (guineo - bananas, frutilla - strawberries, mamones - achotillo here, lychee to my Asian friends in med school, rambutan in Wikipedia). 

 Mamones, or achotillo, or lychee.

I did get to out with some of the residents to nearby Puyo to try volquetero.  From what I can tell, it is sort of like a poor man's ceviche, made from a mix of chocho (a bean-like fruit/seed), maiz tostado (toasted corn), chifles (dried banana chips), tuna, and a salad of cebolla (onion) and tomate (tomato).  It was great!  I also got to try encebollado at a special breakfast at work, a traditional breakfast food, which also includes chifles, fish, tostados, yucca, tomato, and ají.

This is pretty much what our volquetero looked like, including the chunk of tuna from a can on top! 

Most of the other foods I have tried have been fruits.  Many are made into jugos (juices) that I drink at each lunch I buy:  frutilla/fresa (strawberry), mora (raspberry), tomate de arbol (tree tomato), guayaba (guava), guanabana, naranjilla (little orange), granadilla, etc.  Some of the ones I got at the store as well as others are pictured below. 

 

Pepino dulce, or sweet cucumber.  It was a fairly mild, bland, crisp fruit.  The name is appropriate.

 

Babaco, which is currently sitting in my fridge as I wait for it to turn more yellow, is supposed to be good made into a juice.  There is a blender in my apartment, so I plan on figuring out how to use it.  (We don't have one at my home in Lancaster, and I've never done much with one.  I think you just push buttons.  How hard can it be?)  :)

 

 Maracuyá, or passionfruit, is the yellow fruit which has a tart inside usually made into juice.  A patient gave me a whole bag of tomate de arbol, the red fruit above, so I need to make that into juice, too.

                              

I don't remember what this one is called.  I think I'm supposed to just cut it up and eat it.  

 

This is granadilla, which has sweet pulp surrounding black seeds on the inside, all of which you eat (although not the shell.

Not pictured are the papaya I recently bought at a small stand here in Shell and the lemons (called that although they're more like a cross between a lemon and a lime) we pick off a tree outside the residents' house to squeeze onto fish, avocado, and many other things.  Most Ecuadorian main dishes are accompanied by ahí, the national version of hot sauce that I think also has garlic and onions in it.  It's not very hot, at least in my limited experience, but does add a nice additional flavor.  Patacones (fried green plantains) seem to be a common side in restaurants, but platanos maduros (fried ripe plantains) are less common although often available upon request.  Yucca is common, both as a side and in soups.  Soups are very common - every lunch I buy has a soup on the side.  I have not found a lot of vegetables besides tomatoes, and I am very much looking forward to getting home, starting my garden, and eating my usual half-plateful of vegetables each night for dinner.  That said, I will miss trying new things, drinking freshly made jugos, and how cheaply I can buy fresh fruit here.