arrival and adjustments

After two missed flights and two re-bought flights in the past week and a half, two flight delays and reschedulings of connecting flights, some stress-filled and near-tears unloading of my frustrations on my family and boyfriend, and several hours of lines for check-in and security, I arrived in Ecuador at 8 am the morning of Easter Sunday and to Quito, my pick-up point, around 11:00 am.  Guided by a sign with my name on it, I met up with a driver arranged by HCJB (the missions organization who run the hospital) who drove me to one of the missionary docs and his family, who then drove me to with them back to Shell. 

The drive through the Andes down to the edge of the Amazon basin was gorgeous with beautiful peaks and crevices, many small waterfalls and streams from the heavy recent rains, and green, green, green.  It was interesting watching the vegetations change from tall coniferous-looking trees to the jungle-like ones with a patch of leaves a top a bare trunk, palm-looking trees, and giant ferns.  Random bits of color in bright flowers were scattered throughout both types of foliage.

 (not mine b/c I lost my camera in my bag - only to find it later - but the ride to Shell did look very similar to this)

A brief introduction awaited me on my arrival in Shell, including a tour of the hospital and a showing of where I obtain clean filtered water.  The hospital is certainly the best-equipped mission hospital where I have worked, at least in the sense of Western medicine.  It is divided into consulta externa (outpatient clinic), the inpatient hospital, and emergency (three emergency rooms with OR-like lights, suture kits, specula, neb machines, etc.).  There are ventilators, including for children (although most [all?] are old), and incubators.  I can order cultures and electrolytes, luxuries I didn't have at the hospital I rotated at in Zambia in medical school (see the beginning of this blog for some of those stories). 

 
It's an interesting mix of what I'm used to from previous experiences overseas and things that are more like the States.  Send-out labs to Quito (including uncommon things like a CA 19-9 tumor marker and common things like a TSH) take 1-2 weeks to come back.  I wash my dishes with the half-solid soap I used in Honduras, but I've dirtied more than one glass forgetting that I can't drink from the tap.  I drink water I've boiled from the tap or gotten from the special treated tap, and I treat all vegetables/fruit in a special solution to kill the germs, but I ate pizza tonight at a restaurant with the other residents and I have 24-hour electricity and warm water in which to shower.  So it's an adjustment, and certainly trying to do medicine all in Spanish is probably the biggest adjustment overall, but in many ways it is not as much of an adjustment as I expected.  I'm working on a post with some patient stories, so look for that in the next few days, but it likely won't be tomorrow since I'm on call.

travel

I recently came across the quote below in a book excerpt I was reading online.  Since I am spending this week on family vacation as a tourist, and I am then traveling to Ecuador for a month rotation at a mission hospital as a working visitor, thoughtfully comparing the two different types of visiting other locales seemed appropriate. I hope it also encourages me to reflect on how I choose to travel.

Mark Buchanan writes in Your Church is Too Safe:  
"[At some point,] we stopped calling people who went on trips travelers and started calling them tourists. Traveler literally means 'one who travails.' He labors, suffers, endures. A traveler—a travailer—gets impregnated with a new and strange reality, grows huge and awkward trying to carry it, and finally, in agony, births something new and beautiful. To get there, he immerses himself in a culture, learns the language and customs, lives with the locals, imitates the dress, eats what's set before him. He takes risks, some enormous, and makes sacrifices, some extravagant. He has tight scrapes and narrow escapes. He is gone a long time. If ever he returns, he returns forever altered ….

"A tourist, not so. Tourist means, literally, 'one who goes in circles.' He's just taking an exotic detour home. He's only passing through, sampling wares, acquiring souvenirs. He tastes more than eats what's put before him. He retreats each night to what's safe and familiar. He picks up a word here, a phrase there, but the language, and the world it's embedded in, remains opaque and cryptic, and vaguely menacing. He spectates and consumes. He returns to where he's come from with an album of photos, a few mementos, a cheap hat. He's happy to be back. He declares there's no place like home."

                   

Moving from the relaxation of vacation with its reading, swimming, and playing games to the responsibility of caring for patients in my second language, writing medical notes in the chart and communicating on rounds in Spanish, and learning to treat tropical diseases rarely seen in the States is quite the shift.  Still, despite its necessary short-term nature (required in residency training programs nationwide), I definitely hope to create/continue patterns of traveling in the first way described. 

Indeed, I look forward to some of the changes.  I remember feeling in my semester in Costa Rica in college that Spanish was sometimes more my heart language than English; that I could say certain things better - more precisely - in Spanish; that I acquired an altered personality,  style of interaction, and linguistic prosody (the musicality of speech) when I switched to Spanish; that with my affectionate family, ability to tan, and short stature, I seemed to fit so naturally with Latin culture's demonstrative nature and its generally smaller, darker-skinned people.  I look forward to the chance to flip the coin (myself), to show this other side of me that always exists but now only shows in my much-enjoyed encounters with Spanish-speaking patients at work.

But I also have traveled enough to know that journeying brings its own challenges.  Flexibility is required of an international traveler, and this may not naturally jive well with my desire to plan out the details of my future.  Some cultural differences do not come naturally, and humility is an asset in evaluating the way that cultural differences compare to my home culture.  Loneliness can be a frequent companion separate from my usual surroundings of familiar friends, coworkers, family, and church.  Even the language switch, as fun as I find it, can demand enough mental effort to bring me to exhaustion by the end of the day, not to mention the challenges of a different medical environment.

 from:  http://my-bellavita.com/fine-print/adjusting-to-expat-life-in-italy-riding-out-the-culture-curve/

However, if Jesus is my ultimate example of one living a cross-cultural experience and dwelling with a people who are "other," surely I need to be willing to dwell where I am (even for a month) in a way that may cost me in order to love others well. It remains to be seen what this will look like, but I want to go into the experience willing to be flexible, to change the way I naturally or habitually do things, to form new friendships even if I am transient, to learn a language, culture, gestures, history, economy, and politics not my own. My hope is that through traveling and encountering people who are "other" and yet still God's children as much as I am, I may learn more of what it is to journey well through life, whether or not it gains me more stamps in my passport.

lessons from a relationship

I recently began a new relationship.  As is a new relationship's wont, it has been much on my mind.  This post goes through some of the things I have reflected upon as we have moved through the initial weeks of getting to know one another, particularly as it relates to the faith relationship I have with God.

I am struck by how much of the relationship itself consists in waiting.  We date because we don't know whether this will work out in the end, so we're waiting on a final verdict from one or both of us on the relationship itself.  Traditional in some ways at least, I (usually) wait for him to call.  We wait for the next step in the relationship itself as we gradually get to know each other better and so move to different levels of sharing.  But don't get me wrong.  Despite all the waiting inherent in this process, I am definitely enjoying the process itself!  It's just that it has struck me repeatedly that a relationship is just this:  something already but still a process of becoming what it will be.

Waiting in the context of a relationship recalls to mind the already/not yet tension present in the way Scripture talks about the Kingdom of God and Jesus' present reign on earth.  In some ways, it is already here, changing lives, working powerfully in this world, but in other, significant and substantive ways we still wait for the already-won Kingdom to be made manifest in our lives and this world.  We wait for the fuller, deeper thing even while we enjoy the very good thing we already have and glimpses in what we have of what is to come.  In this hurting yet wonder-full world and my fun yet becoming relationship, we wait, in hope.

I have been struck as well by the vulnerability that arises in me through this relationship.  I am used to being what I have been for most of my adult life:  basically an independent person.  Instead, suddenly my whole day's outlook can be changed dramatically by this single other person - whether he calls or not, what he says in an email, an unexpected letter, etc.  Just thinking of him brings a smile to my face, and my friends' teasing easily makes me blush.

So far the vulnerability has brought all good things; the cloud of euphoria that accompanies the early phase of a relationship makes me a very happy person!  But I know the power is there as well for one of us to hurt or disappoint the other, for careless words to wound, for lack of contact to inspire a loneliness I wouldn't have felt so keenly a few months ago.  It's a power that's scary to acknowledge in myself as well since both of our (not just mine) investment in the relationship and each other brings this vulnerability to the other.  It's a risk I take, acknowledging it as part of the necessary process of a relationship, but it's not one I take lightly for either of us.  It's helpful on my end to remember the trust I am forming through experience in the character of my boyfriend (and to work on making choices that form me into a person of character worthy of trust).  It is good, too, to remember other influences on my well-being - the stable, unchanging love of the Father who calls me beloved (this music video recently made me cry); the family who loves me wherever I choose to go and whatever choices I make; the friends who so willingly rejoice with me.

The next theme of my reflection has been on the idea of hope.  Two months ago, I didn't know this guy existed.  Now, my life has changed dramatically in the space of days and weeks to reflect his existence - how I spend my free time, where my thoughts are, even how I relate to others.  It's a simple but powerful reminder of how much a relationship can change us. May my relationship with Jesus affect me as much!

In Hebraic thinking, our "heart" was much more than our emotions; it also was the locus of the will and in some ways encompassed the orientation of the whole person him- or herself.  Thus, out of our hearts flow our actions, our priorities (cf. Mt. 6:21), our thoughts.  It makes me reflect carefully about where I am turning my heart, which leads me to my next thought.

I have been humbled in entering this relationship by the whole comparison of this earthly early care to my love for and relationship with God.  I am struck by how quickly my thoughts go to him, how naturally I delight in spending time with him, how easily my joy and excitement overflow into sharing about him with others.  Would that I had the same thoughtless, carefree joy and delight in my relationship with God!  How might others respond if I as easily began talking excitedly about God as I do about my last weekend?  Would they be drawn to Him when they see the glow he puts on my face?  How often do I consider Jesus' reactions to my day, ways to integrate him into the interactions I have, regular sharing of my thoughts and emotions for the sake of having another reflect on them to me, perhaps gently pointing out where I fall short of Jesus' example? 

I am sure there will be more lessons along the way, as there can be in any relationship but most strongly in the commitments where we make ourselves vulnerable.  But for now, I'm enjoying the process and learning to wait, seeking to learn to live responsibly with both my own power and vulnerability in this new context, and aiming to orient my life - this relationship included - around the one Romance that can define and transform me in ways that prepare me to live all other parts of my life.  May my love for Him grow and overflow in joyous abandonment that draws those around me to and reminds me of the worth of (as Chesterton put it in Orthodoxy) this lived Romance, a combination of strange and secure, wonder and welcome, happiness in this "wonderland" without "once being merely comfortable."

stories

25 y/o G2P1 (second pregnancy, one child already delivered) presents to triage at 38 wks with no prenatal care in labor with a baby found to be double footling breech (both feet down instead of head down).  Baby is born by emergency c-section, and mom decides to give him up for adoption.  I talk her through the possibilities of open vs. closed, available agencies.  I hold her hand as she cries over her selfless decision, over the baby she holds and gives away.  I rejoice quietly with her as she picks a family from the profiles the agency showed her, a family with another little boy, a brother for her baby.  I marvel silently at the strength she shows.

21 y/o G1P1 seen in clinic for routine gyn care.  Oh, by the way, my last period was more than a month ago, a bit late now, unusual for me.  We chat around the Pap and pelvic exam about the Gardasil vaccine and contraceptive options, her life living with her mother to save money to stay at home with her two-year-old, her questions about this or that health-related topic.  Near the end before signing the orders for some vaccines and prescribing her birth control choice, I check a pregnancy test just to be sure.  Positive.  I go back in to tell her, and she bursts into tears.  I sit back down, wondering inside at the irony that there are people who would cry tears of joy for this positive test that only brings pain and chaos to my patient and her life.  We chat about options, me recalling my last difficult conversation with a patient in a similar situation who I now see for regular prenatal care since she never went for that abortion she had initially planned.  I give this patient information about resources related with all her options - parenting, adoption, abortion - advising her of the support available for her should she choose to parent or form an adoption plan.  I wish again that I had easy answers about my role in this counseling, my patient's decision, or at least an easy spiel of what to say and how to say it instead of the ambivalent wading through beliefs and values, situations and specifics, reactions logical and emotional.  We agree to meet up again in two weeks to talk about her final decision.

 55 y/o woman with known history of alcohol abuse comes in with alcoholic hepatitis.  She is then intubated for hepatic encephalopathy with failing liver and eventually kidneys, too, as she develops hepatorenal syndrome.  Unexpectedly, she survives her extubation planned for when her family can be there and moves slowly towards comfort measures as she is now alert enough to make her own health care decisions.  I visit her the weekend before she moves to inpatient hospice to check on how she is feeling and end up sitting at her bedside giving her sips of the dozen or two juice bottles beside her bed and spoonfuls of cool sherbet that make her dry mouth less uncomfortable as her failing liver's inability to make protein to keep the fluid in her blood vessels slowly allows her to become more swollen otherwise and more dry inside the vessels.  I lotion her dry, jaundiced hands and arms, recalling the elderly nursing home residents for whom I did this routinely for five summers through college.  I wonder about how she must feel, relatively young and knowing that her drinking caused this poisoned liver, the dry itchy skin, the slow dying.  Vicarious regrets fill me, and I mourn for what her life could have been.

27 y/o woman with family history of blood clots comes in with chest pain and shortness of breath.  She is mildly anxious (never having been to the ER as a patient before), tachycardic (fast heart rate), tachypnic (fast respiratory rate), but pulse ox is normal.  She tells the ER physician of her family history and risk factors for blood clots - the birth control pills she started herself on for acne, the long trip out to Indiana and Minnesota to see friends and family on her one-week vacation from residency a week and a half ago.  She is found to have a pulmonary embolism (blood clot) in her lungs and is placed on blood thinners for the next six months.  After the blood thinner level comes up appropriately and her pain is controlled, she goes home to stay with her parents for a few days to recuperate.

A routine case - one I have seen two or three times already this year in various transmutations - except that this time six weeks ago the patient was me.  It has been frustrating and educational to be on this side of medicine for a change, getting regular blood work, waiting for phone calls from my own doctor for dosage changes on medications based on the labs, filling prescriptions at the pharmacy and bemoaning how expensive medications are (and I have good insurance!).  I also identify more now with the fear of being in pain before the diagnosis is made, the lack of control over a body that no longer acts as it normally does (short of breath with walking, pain when lying down flat to sleep - now all resolved, thank God).  And I am grateful for the family and friends (despite being in this place for only seven months) that support me during the time when I felt sick as well as now when I now feel normal but still have to do the follow up things (blood work, making up the week of work I missed, occasional checkups).

update

So it's been a while since I posted, and I had some thoughts I'd like to share or at least have the chance to process externally.  I hope to continue to do this throughout the year ahead (albeit much less frequently than during my previous travels) as I start residency.  If you don't want to continue to follow along, let me know, and I'll see if I can figure out how you can come off the list.  :)

I graduated from med school at the end of May and moved the same day - with much packing and hauling help from Mom, Dad, Grandma, and Grandpa - to Lancaster for my new residency training.  I enjoyed starting a garden and putting in flowers and landscaping in the surprisingly large backyard of my housemate's rowhouse prior to the start of orientation June 14.  I also have gotten to attend First Friday downtown in Lancaster, go to two free downtown movies (part of summer series), and begun getting to know my fellow interns (via hosting dinner and later dessert and other local activities), a couple of whom live happily about two blocks away.  :)  We've had a busy orientation schedule between ACLS, ATLS, EKG learning, computer training, HR paperwork, and even a day at the ropes course.  I've enjoyed the chance to ease into figuring out where stuff is in the hospital, making connections with my class and other residents, and settling into the city.  I start in the hospital July 1 on night float for OB (5 pm-7 am Monday-Friday for two weeks), so you can keep me in prayers for that!