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I’m approaching being 2/3 of the way through residency. *Gulp!*. My opportunities for writing have been fairly minimal for the last two years but, as ever, I am optimistic I’ll have more time in the future. This is something I wrote almost 4 months ago, which remains relevant, and which I’ve finally sat down to publish. I hope you find it thought provoking. 

 

I tend to be a pretty upbeat person. I’m not sure whether I have extra-sensitive serotonin receptors, or higher than average baseline dopamine levels, but I’m definitely someone who tends to be optimistic. Even working 80 hour weeks, I was recently described as “bubbly”.

 

That being said, it’s hard to stay positive these days when you tune into the news. With terrorist atrocities (international and domestic), attacks on women’s health, disregard for refugees, and stigmatization based on religion, race, or sexuality, it can be hard to stay positive in the face of so much hate.

 

 

I struggle to understand the hate that is freely and vitriolically expressed on social media, on some news outlets, and by some political candidates. As someone who finds solace in understanding, and also thinks that natural selection is everywhere, I’ve been trying to understand an evolutionary basis for this general grumpiness.

 

Before digging into this subject I think it’s necessary to preface the conversation with Hume’s Law aka Naturalistic Fallacy, or in plain English: the is/ought problem. Though we may accept that there is an evolutionary basis to this hatred, we are not saying their ought to be. On the contrary, I would argue that it is important to understand why this hatred exists so that we might better understand each other’s perspectives. I think we can all agree that the current plan of yelling at each other as loudly as possible isn’t moving the conversation forward in any meaningful way.

 

When I first started to think about this subject I was immediately reminded of Baba Brinkman’s “Rap Guide to Human Nature”. (I’ve written about Baba and his Rap Guides here). One of his songs addressed the differences between conservatives and liberals, touching on xenophobia. True to form, the song is well researched and backed with science. You can hear the song here, or you can watch a live version here (which is worth watching at least for a couple minutes since his preamble nicely summarizes some important research).

 

Baba’s argument (formed from the work of a number of scientists) is that xenophobia is part of our Behavioral Immune System– an evolved psychological response to things that could threaten disease or illness. This is the mechanism that makes us averse to the smell of food that’s gone bad, people that look infectious, and (in the case of xenophobia) people that look foreign who may be carrying some foreign disease.

 

This argument is only one of many evolutionary ‘reasons’ that we may have a fear of outsiders. A very simple reason, and one we frequently see cited by those opposing aid to refugees, is the conservation of resources. If you have only limited resources, there is an evolutionary benefit to sharing with those who are related to you, those in your in-group, instead of sharing with outsiders. You can see this theory in action in some of our more distant relatives. Chimps, for example, are very territorial, and are often horribly aggressive to members of outside groups in order to protect their territory and their resources. On the other end of the spectrum are Bonobos, who live in more resource rich environments and who are often friendly to outside groups. There’s a quick public radio piece on this subject here.

 

This is a very long lecture (or series of mini-lectures), but I thoroughly enjoyed watching and listening to this one quiet evening on night-float. If you have the time, it’s well worth a watch.

 

There’s far too much covered in these lectures to distill into a blog post, but I think the closing comments are very powerful.

 

“We have biology, and we have our brains. And we have this incredible problem of fear which has a real basis. But we need to overcome that to live together. But the only way we can really do that is to understand what it is that makes us afraid of others and how the biology works, and how the psychology works, and to try to answer those questions. And so the only way we can ever, it seems to me, move forward, is try to understand what makes us up as human beings.” -Lawrence Krauss

 

So how can move forward? I have touched on only a couple of the evolutionary reasons for fear, but even on those subjects there is a lot to be done. Baba brings up the point that for some countries wracked with social issues, the answer may (at least in part) be water sanitation and vaccination- protecting people from the things their behavioral immune system has evolved to fight.

 

Here in America (and in much of the developed world), I think the bigger issue is resources. A frequent cry one sees on social media is along the lines of “how can we care for refugees when we can’t care for our veterans”. Much as food scarcity in chimps can cause hostility towards outsiders, lack of access to secure housing and healthcare may be a major cause of hostility towards refugees in our society. It seems that many fear that something they pay very dearly for may be given for free (with their tax dollars) to outsiders. It certainly doesn’t help that we currently live in an economic environment where many are living paycheck-to-paycheck, and we are not far gone from the time with economic collapse caused many to lose their homes. I think it is no coincidence that the countries in Europe that are accepting the most refugees have solid national healthcare and safety-nets, where their citizens do not live in fear of paying their next bill, or not being able to care for themselves or their family. Obviously there is no easy fix for the situation we are in, though I think that access to healthcare is an important place to start.

 

From the lecture series above (it really is great):

 

“Simple assumptions: that trade or interdependence or interaction will be, by itself, sufficient is unfortunately too easy, but sets for us an important challenge. It seems like often in human society when there is plenty, everything is fine, and then when stress occurs, when there is limited resources, when there is a need to retract, if you take the crystal of human society and somehow hit it, group boundaries is where it breaks. But not always. And so what I think what we want most to know is what are the keys to resilience and resistance. How do you create a society that, when put under stress, doesn’t break along ethnic or descent based lines.” – Rebecca Saxe

 

And that, dear readers, is a question for another day…

 

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I have a rather embarrassing admission to make: when I first started looking at taking a trip to the Galapagos three months ago I didn’t actually know that the islands were part of Ecuador.  Two months ago I visited the islands. It was amazing, but other than one afternoon in Guayaquil on the way back to the states I really didn’t get a taste of mainland Ecuador.

 

But while touring the Galapagos on the National Geographic Endeavour I made friends with one of the naturalist guides who invited me to come back and visit him in mainland Ecuador.  Always a fan for adventure, and with only minor apprehension about spending 8 full days with someone I had barely spent 8 full hours with, I booked tickets to Quito and packed my bag.

 

The Galapagos Islands are amazing. They are unique, beautiful, and biologically fascinating.

 

A blue footed booby in the Galapagos, with the National Geographic Endeavour in the background.

A blue footed booby in the Galapagos, with the National Geographic Endeavour in the background.

 

Mainland Ecuador is also amazing. It is beautiful, biologically diverse, and inhabited by generous and kind people.  Ecuador has stunning biodiversity, spread over four distinct regions: highlands, jungle (Amazon), coast, and the Galapagos (600 miles due west of the mainland).

 

Quilotoa- more on this beautiful place later, but this is one of may beautiful spots that you can visit in the highlands of Ecuador.

Quilotoa- more on this beautiful place later, but this is one of many spots that you can visit in the highlands of Ecuador.

 

I landed in Quito, the capital, late in the evening on the first where I met my friend and started our adventures.  Quito airport is new, and located about an hour outside of the city.  There is a nice airport express bus that takes you to the old airport in town, from where we took a taxi to Plaza Foch- a popular touristic area of Quito (there’s quite a bit of night life in this part of the city, with un-Ecuadorian high prices).  It’s a fun part of town, and despite being a pricey place to eat and drink there are many affordable hostels.  The night we had a room at one called “The Magic Bean” (coffee was a theme).  Throughout the rest of our trip we stayed at various hostels, never making plans or reservations until we arrived.  Hostels were generally cheap: we paid $19-$40/night for 2 people, always with our own bathroom, and sometimes with breakfast or breakfast and dinner included.

 

My first morning we wandered around Quito, grabbed breakfast, and walked around Parque El Ejido, all near Plaza Foch.  Quito is in a valley, stretching from north to south (with the old colonial district in the middle, dividing “the North” (which is more prosperous) from “the South”), with mountains surrounding.  The weather in Quito is lovely, and fairly constant.  There’s no need for seasonal wardrobes in Quito-you can wear the same clothes year round.  Since Ecuador is at the equator, sunrise and sunset are fairly constant year round, occurring right around 6am and 6pm.

 

Around midday we headed to a bus station on the north side of the city and took a bus to Mindo.  Ecuador uses the America dollar as currency, and generally speaking things are very cheap.  Public transportation within the city allows you to cross town for $0.25 (12c if you’re a senior or child), and the ~2 hour bus ride from Quito to Mindo was a mere $2.50 (a good estimate on bus rides in Ecuador is ~$1/hr).

Our first destination was Mindo...

Our first destination was Mindo…

 

The trip to mindo took us winding through lush mountains.  Wikitravels recommended sitting on the right side of the bus for the best views and they were right.  The tops of these peaks were often in clouds, though we were at lower altitudes than we had been in Quito.

The trip to mindo took us winding through lush mountains. Wikitravels recommended sitting on the right side of the bus for the best views and they were right. The tops of these peaks were often in clouds, though we were at lower altitudes than we had been in Quito.

 

Mindo is a beautiful small town nestled in cloud-forest.  It is famous for the quantity and diversity of birds, and it is an increasingly popular tourist destination.  My travel companion had visited many years ago, when there were a few hostels in a small town. He was shocked at the number of hostels that are there now, with many more under construction.

 

We stayed at the Dragonfly Inn- definitely the most luxurious of our accommodations during our 8-day adventure, with an attractive and clean room for $50/night for two of us (breakfast included).  The inn is located on the main street, overlooking a small river.  Hummingbird feeders attract lots of hummingbirds, and you see other birds flitting about the trees at all hours.  While eating breakfast on the patio I saw at least 20 hummingbirds buzzing about.

 

These guys were flitting around all the time and were especially active in the morning.  The majority were this variety, though we did see others as well as a stunning yellow tanager.

These guys were flitting around all the time and were especially active in the morning. The majority were this variety, though we did see others as well as a stunning yellow tanager.

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Mindo has historically been a destination for birders, but it is increasingly becoming a hot spot for adventure tourism.  During our stay we enjoyed a hike up at the cascade waterfalls and a tour of the local chocolate “factory”.

 

The cascades at Mindo are about 7km outside of town, and you either hike up the dirt road to the cable car that takes you across to the trails or you catch a truck-taxi.  We opted for the latter option, setting up a return journey a few hours after we were dropped off (this ended up being a great set-up, as it started to pour as we finished our hike).  To access the cascades you take a ride on a generator-powered cable-car that takes you on a ~900m ride across a deep ravine.  Our car-operator would give any OSHA inspector a heart attack, as he opted to stand outside the metal cage as we zoomed along, hundreds of feet above the forest floor.

 

About 900m long, and absolutely stunning... A breathtaking way to reach a trailhead!

About 900m long, and absolutely stunning… A breathtaking way to reach a trailhead!

 

Once on the other side we opted to hike to the Reina Falls (there were a couple of trail options).  There were many small falls along the way, and we spotted many hummingbirds and flowers along our hike.  The final falls, Reina Falls, required a climb up a rather sketchy set of stairs.

 

One of the small falls along the trail to La Reina falls.  Everything was so green and alive!

One of the small falls along the trail to La Reina falls. Everything was so green and alive!

 

I loved these massive tree ferns.

I loved these massive tree ferns.

 

La Reina falls.

La Reina falls.

 

Heading back down the sketchy stairs after we'd visited the falls.

Heading back down the sketchy stairs after we’d visited the falls.

 

Alas, it started to pour towards the ends of our hike, so our cable-car ride back to the taxi was a wet one.  Had the weather been nicer, and had we had the interest, there are a number of outfits that offer canopy rides in the area.

 

A slightly soggy ride back!

A slightly soggy ride back!

 

We had lunch at a little café (trout is a regional specialty, and was delicious), where we had a long discussion with the café owner about the various challenges Ecuador faces when it comes to attracting tourists.  While we chatted (first in Spanish, then in English) the owner caught on to my interests in agriculture and food, and insisted on running to the market next door where he purchased a naranjilla and a taxo (banana passion fruit) for me to try.  Both have distinct and interesting flavors and are generally used for making fruit juice, for which they usually require some sweetening (“jugo natural”= freshly made juice, which is very popular in Ecuador.  A glass of some sort is usually served with breakfast and lunch).

 

Taxo (above) and Naranjilla (below)

Taxo (above) and Naranjilla (below)

 

In the afternoon we headed to El Quetzal Chocolate Factory (Factory is probably a bit of an over statement, as operations take place in a small shed and two processing rooms), where we went on a tour and learned how they made chocolate- bean- to bar (actually pod to bar).

 

Cacao trees have many pods on them at one time and they sprout directly from the trunk or branches.  They ripen at different times, and are red and yellow when mature.  The best beans grow at lower altitudes, so El Quetzal doesn’t use the pods from their plants in Mindo (somewhere between 1000 and 2000m altitude) for making chocolate.  Instead they use these for decoration and/or share the fresh pulp amongst the workers as a snack.

Cacao trees have many pods on them at one time and they sprout directly from the trunk or branches.  They ripen at different times, and are red and yellow when mature.  The best beans grow at lower altitudes, so El Quetzal doesn’t use the pods from their plants in Mindo (somewhere between 1000 and 2000m altitude) for making chocolate.  Instead they use these for decoration and/or share the fresh pulp amongst the workers as a snack.

 

 

Pods are broken open to acquire the beans, which are fermented, as well as the white pulp, which is cooked down into a thick syrup that they call Miel de Cacao.  I really liked the flavor, which had elements reminiscent of balsamic vinegar.  In Mindo the cacao beans are fermented and dried in a plastic-sided green-house- the smell is intoxicating

 

Beans ferment for a few days to a week, depending on the temperature.  They are wrapped in banana leaves to conserve heat.

Beans ferment for a few days to a week, depending on the temperature.  They are wrapped in banana leaves to conserve heat.

 

The heat from the fermentation process kills the "embryo" inside.  Initially these embryos start out purple, and they become brown as they cook and die.  Brown (dead) embryos make good chocolate (there's a reason chocolate is brown and not purple!).

The heat from the fermentation process kills the “embryo” inside. Initially these embryos start out purple, and they become brown as they cook and die. Brown (dead) embryos make good chocolate (there’s a reason chocolate is brown and not purple!). This one is on it’s way to being ready, but is still quite purple.

 

Once fermented, beans are laid out to dry.  Drying time depends on the temperature in the house. 

Once fermented, beans are laid out to dry.  Drying time depends on the temperature in the house.

 

Once the beans are dried, any bad ones are removed and the remaining beans are roasted and cracked.  The nibs are separated from the shells by a winnower.

 

The Roaster- Much like the fermenting and drying room, the smell in this room was intoxicating.

The Roaster- Much like the fermenting and drying room, the smell in this room was intoxicating.

 

This is what you get after you roast the beans: nibs and shells. Throughout the process we were encouraged the try the beans.  As someone who enjoys 100% cacao, I enjoyed nibbling on the nibs.  Not so for the other 3 people on the tour.

This is what you get after you roast the beans: nibs and shells. Throughout the process we were encouraged the try the beans.  As someone who enjoys 100% cacao, I enjoyed nibbling on the nibs.  Not so for the other 3 people on the tour.

 

Next, production moves into the first processing room where beans are ground.  Here the beans were either made into 100% cacao paste, or separated (with pressure) into cocoa butter and cocoa powder.  The thick chocolate paste, known as chocolate liquor, is then made into chocolate bars by adding sugar and extra cocoa butter.  The mixture is refined, conched (ground and processed for a long period of time- I believe over 24 hours), and then tempered.  El Quetzal doesn’t add any emulsifiers (such as soy lecithin), and instead relies on extended periods of conching and tempering to get a lovely smooth mouth feel and texture.  They make a few different bars with various amounts of sugar and some added ingredients, such as ginger, chile peppers, and coffee- all of which they grow in Mindo (they also ferment a potent, and delicious, ginger beer).

 

I could have spent a couple of days in Mindo, but the next morning we headed back to Quito so that we could catch another bus to Otavalo.

 

The route to Otavalo.

The route to Otavalo.

 

Otavalo is a (relatively) large city in Imbabura province that is largely inhabited by native people.  Otavalo is known for it’s large market (mainly selling locally manufactured textiles and leather goods), which has made the city and its people prosperous.  The market is open every day of the week, but the largest market is on Saturday.  We arrived on Friday evening, found a hostel (for $19/night for 2 people), took a brief walking tour of the market area, had some dinner, and called it a night.

 

The market in Otavalo, as business was winding down on a Friday night.

The market in Otavalo, as business was winding down on a Friday night.

 

On Saturday morning we woke up early to go to the Mercado de Animales.  This market is only open on Saturdays, and is where locals go to sell, buy, and trade all sorts of animals: cows, pigs, goats, sheep, llamas, chickens and assorted poultry, rabbits, and guinea pigs (known as cuyo). I’ve never seen so many pigs on leashes…

 

Early morning in the mercado de animales.

Early morning in the mercado de animales.

 

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Looking out over the cow section.

Looking out over the cow section.

 

Pigs on leashes!

Pigs on leashes!

 

Piglets on leashes!

Piglets on leashes! (I thought the spotted ones were very cute)

 

One of the few things I found in Ecuador that was actually more expensive than at home in the states was old laying hens.  Here I know farmers that get $2.50/bird for old laying hens, while they were selling well for $9 a pair in this market. “Galina” (hen), has more flavor than regular meat chickens “pollo”, at least according to my travel companion!

 

A woman wearing her baby and selling Gallina (old laying hens).  At $9/pair, these are more expensive than in the US!

A woman wearing her baby and selling Gallina (old laying hens). At $9/pair, these are more expensive than in the US!

 

Lots of Gallina: hens that have stopped laying eggs.

Lots of Gallina: hens that have stopped laying eggs.

 

Alternatively, you could buy pollo- meat chickens (I didn't catch the price).

Alternatively, you could buy pollo- meat chickens (I didn’t catch the price).

 

I asked if you could buy laying hens (what we would call pullets), and was told that no one would sell a good laying hen.  You could buy chicks though- I assume the brown paper bags on the side are for transportation once sold.

I asked if you could buy laying hens (what we would call pullets), and was told that no one would sell a good laying hen. You could buy chicks though- I assume the brown paper bags on the side are for transportation once sold.

 

Guinnea pigs are a traditional meat source in this part of the world, and were prevalent in the market.

Guinnea pigs are a traditional meat source in this part of the world, and were prevalent in the market.

 

A mix of guinneas and rabbits.

A mix of guinneas and rabbits.

 

People shopping in the Otavalo animal market.  It's kind of nice to be in a market where no one is trying to sell you anything.  It's pretty obvious that tourists won't be taking anything home, so you're left to wander around and people-watch to your hearts content.

People shopping in the Otavalo animal market. It’s kind of nice to be in a market where no one is trying to sell you anything. It’s pretty obvious that tourists won’t be taking anything home, so you’re left to wander around and people-watch to your hearts content.

 

Vegetable oil- the bane of my existence… I was sorry to see this guy selling vegetable oil at the animal market.  Why abandon lard! (They’re getting the “animal fat is bad for you, vegetable oil is good for you” story in Ecuador these days.  Also, while people cook most things from scratch outside of the big cities, there were lots of billboards marketing pre-made convenience foods as the way of the future. 

Vegetable oil- the bane of my existence… I was sorry to see this guy selling vegetable oil at the animal market.  Why abandon lard! (They’re getting the “animal fat is bad for you, vegetable oil is good for you” story in Ecuador these days.)  While people cook most things from scratch outside of the big cities, there were lots of billboards marketing pre-made convenience foods as the way of the future.

 

After leaving the animal market (and passing through the small black-market out front where people sold animals without having to pay the $1 fee for trading animals in the market) we headed back into town to check out the main market.  On market day, the central square and two main streets are full of vendors selling silver, leather goods, antiques, and clothing made in and around Otavalo.  I couldn’t resist coming home with a small collection of scarves (made of locally produced cotton) which I bought for $2.50-$3 each.  The main materials produced and used for textiles in the area are wool, cotton, and alpaca, and while most things are made in bulk on machines you can still find a few vendors that hand-make their own items.

 

I bought a few scarves from this young lady, who sold alpaca and cotton scarves, as well as wool hats that she knits herself (I somehow resisted the sponge-bob hat). 

I bought a few scarves from this young lady, who sold alpaca and cotton scarves, as well as wool hats that she knits herself (I somehow resisted the sponge-bob hat). She was very smiley while we chatted but became very serious when I asked her if I could take her picture.

 

I loved the colors of these locally produced wools.

I loved the colors of these locally produced wools.

 

Some general observations of the people in Otavalo:

 

The majority of people in Otavalo are indigenous Ecuadorians, and while they generally speak Spanish they also speak their own dialect of Kichwa.  The women frequently wear traditional embroidered blouses with matching ribbons wrapped around their pony tails.  They often wear hats, but will substitute a folded up blanket on their head to keep the sun out of their eyes in a pinch.  The women generally wear flat sandals or shoes, and have no qualms breastfeeding in public.  Babies are frequently worn in makeshift slings on mothers’ backs, and I didn’t hear or see an unhappy baby the whole time we were there.

 

A folded blanket doubling for a hat in the animal market.  Women will walk around all day with a blanket like this.

A folded blanket doubling for a hat in the animal market. Women will walk around all day with a blanket like this.

 

In the afternoon we headed to Cotacachi- another predominantly indigenous town- famous for leather work.  After meandering the main stretch and grabbing lunch (a delicious $7 per person “menu del dia” that consisted of traditional ceviche, plantain soup, a trout main dish, and strawberries with cream), we got back on a bus to make our way to Vale de Chota via Ibarra.

 

Valle del Chota is not a typical tourist destination.

 

Valle del Chota is a region in Imbabura province with a number of small villages and towns occupied largely by Afro-Ecuadorians.  Along with the Esmeraldas province, Valle del Chota is one of the two areas in Ecuador largely inhabited by black Ecuadorians (descendants of former slaves and those who escaped from wrecked slave-ships coming from Africa).  The villages in this area are generally rather poor (with some living in abject poverty).

 

Onwards to Valle de Chota

Onwards to Valle de Chota

 

Perhaps some would find a visit to Valle de Chota interesting because of the heritage of the people or to see the difficulties of living in poverty, but we came for another reason… While people in this area traditionally scratched out a living trying to do agriculture in a very dry environment, this area has now become famous for the production of something very different- futbol (that’s soccer for Americans) stars.

 

Despite being a mere dot on the map of Ecuador, this region has produced half of the players on the last two Ecuadorian world cup teams.  Players from these towns compete in Europe and around the world, and are internationally recognized as sports stars.  While I have no interest in soccer my travel companion is a huge futbol fan, so exploring these towns was of great interest to him.

 

We started our morning in Pusir Grande- the most impoverished place I have ever visited. The easiest way to get to this village is on foot over a large suspension bridge built in 2004.  In Pusir we spoke with a pair of older women who told us about life in the village.  It was not a pretty picture, with no real jobs, no real opportunities, and no real way out.

 

The bridge to Pusir.

The bridge to Pusir.

 

 

The view from the bridge is stunning, but the sights in the village on the other side take your breath away for totally different reasons.

The view from the bridge is stunning, but the sights in the village on the other side take your breath away for totally different reasons.

 

Pusir Grande- Absolute poverty- there really isn’t much for me to say.

Pusir Grande- Absolute poverty- there really isn’t much for me to say.

 

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From Pusir we took a taxi to Juncal.  The taxi was driven by a local young man who was excited to have some tourists visiting his area.  When he heard our reason for visiting he told us that he would take us on a detour through his town of Carpuela, where he proudly pointed out the houses of family members of various famous soccer players (the names meant nothing to me, but my companion was excited).  Carpuela was definitely better off than Pusir, and conditions continued to improve as he hit Juncal (though I would not call the area prosperous).

 

In Juncal we had a traditional lunch of Fritadas (fried pork served with a couple types of corn and potatoes).

 

Fritadas

Fritadas

 

We then walked through town, eventually meeting up with a group of young boys who found a couple of out-of-towners very entertaining.  They took us down to the river and regaled us with stories, attracting more young boys with their shouts and laughter.  I spoke to them all with my basic Spanish, and as each new boy showed up they asked me “Conoces Libby?” (Do you know Libby?) Apparently they have a visiting American teacher named Libby.  The boys were also fascinated by how my friend and I could be together because my Spanish was so bad… For some reason they had a hard time believing that he was fluent in English.

 

These guys were great and full of life.  Maybe one will be a famous soccer star some day.

These guys were great and full of life. Maybe one will be a famous soccer star some day.

 

I spotted this girl watching us on our walk back to town. Only the boys came up to us to say hello.

I spotted this girl watching us on our walk back to town. Only the boys came up to us to say hello.

 

Under the bridge- this is where some of Ecuador’s best soccer players grew up, with this field being the training ground for World Cup players.

Under the bridge- this is where some of Ecuador’s best soccer players grew up, with this field being the training ground for World Cup players.

 

On our way back through town we stopped to watch some Ecuavolley.  As the name suggests, this is a variant of volleyball, invented in Ecuador.  The game is played with a soccer ball (it’s hard enough to afford one ball, you might as well use it for multiple sports), and is played three-a-side.  During my stay in Ecuador I watched a number of these games (my companion is an avid and accomplished player).  At this game, and throughout our stay in Valle del Chota, I stood out like a sore thumb (as did my relatively pale Ecuadorian friend) but while our presence drew some interested looks we never had any issues and were frequently offered assistance (because surely we were lost!).

 

A street game of Ecuavolley.

A street game of Ecuavolley.

 

It looked like fun. I'd certainly like to try it out!

It looked like fun. I’d certainly like to try it out!

 

In the afternoon we again headed back to Quito.  While we easily navigated Ecuador by bus, we always had to return to Quito to start a new adventure, with it acting like the hub of our travel wheel.  We again spent the night in Plaza Foch, before heading south to Quilotoa (changing buses in Latacunga- the capital of the Cotapaxi province).

 

The roads to Quilotoa...

The roads to Quilotoa…

 

Quilotoa is a beautiful crater lake in an area sparsely populated by native people.  Due to it’s growing popularity as a tourist destination, the locals have moved from their old village which was located about 1km down the mountain and are now living up at the edge of the crater where you can find many hostels and small cafes or stores (every building is a café, store, or hostel, as all the inhabitants make their living from tourism).

 

One of the many hostels in Quilotoa,flying the Incan flag.

One of the many hostels in Quilotoa,flying the Incan flag.

 

 

My friend had visited Quilotoa 15 years ago, when you had to hire a truck to take you up the dirt road and the only thing at the top of the crater was a small adobe hut.  In the last few years the government has paid for the construction of a nice new road to the village as well as the construction of a handicapped-accessible viewpoint and a maintained trail down to the lake.  With these changes, tourism continues to increase, though there weren’t many other visitors during our stay.

 

This nice wide trail is a relatively new addition to the landscape at Quilotoa.

This nice wide trail is a relatively new addition to the landscape at Quilotoa.

We opted to stay at one of the first hostels we saw- a recently constructed large chalet with beautiful large rooms heated with wood burning stoves.  At almost 4000m (12,841 feet) and exposed to the elements, it’s windy and chilly in Quilotoa and we were certainly appreciative of the stove in our room and in the common area.  For $20/person we not only had a room, but also had a dinner and breakfast that we shared with the other visitors (including four Indians who are on a months-long journey culminating in a trip to the FIFA World Cup in Brazil and a young Japanese woman on a solo year-long trip around the world!).

 

In addition to running a hostel, the owner of this establishment makes and sells wooden masks.  In the back you can see him wife tending to the wood-burning stove.

In addition to running a hostel, the owner of this establishment makes and sells wooden masks. In the back you can see him wife tending to the wood-burning stove.

 

We got to Quilotoa in the early afternoon.  We had lunch at a small café associated with our hostel (a $4 menu del dia consisting of a bowl of lima bean soup, a plate of chicken, potatoes, and rice, and a glass of fresh-squeezed juice) and then headed to the crater.  Despite a bit of concern that we may not make it down and up the crater before dark, we headed off down the trail.  There we chatted with a local guy who was maintaining the trail.  I figured that these guys must be used to tourists, so I asked him if he would take a picture of us with my digital camera.  My assumption was wrong, and I don’t think I’ve ever seen someone have so much trouble taking a picture.  Eventually there was success, and while the picture may be crooked, and you may see only part of the crater lake, our smiles were certainly genuine.

 

My travel companion is a photo instructor for National Geographic, a skill that definitely came through in some of the pictures that he took with my camera!

My travel companion is a photo instructor for National Geographic, a skill that definitely came through in some of the pictures that he took with my camera!

 

It probably took us about half an hour to make it to the bottom of the lake, and I’ll admit that a couple times I found myself concerned about our ascent up the steep path, especially with the added difficulty of catching our breath at altitude.  At one point we passed a local giving a tourist a ride up the trail on a horse, but we declined his offer to come back and get us from the base.

 

The lake at the base of the crater.  The colors of the lake are amazing, and changed with the angle and intensity of the sun.

The lake at the base of the crater. The colors of the lake are amazing, and changed with the angle and intensity of the sun.

 

At the bottom of the crater you can rent Kayaks for $2.50/hour, but they had shut-up shop by the time we got there.  There is also a very basic hostel on the shore, which provides a bed and breakfast for ~$12 a night with access to a pit toilet.  There are no wood-burning stoves in these rooms, but it was much milder down in the crater than up at the rim.  We found a young local down at the hostel, and we chatted to him a little bit before starting our hike back to the rim.  He said it takes him 25 minutes to hike back up, though I’m sure it took us well over twice that.

 

On our return hike we opted to take a different path, rather than the maintained trail.  It was very challenging, but the views on this hike up and down were absolutely breathtaking.  The water is a stunning blue, with the color changing dramatically depending on the light.  The water is brackish and full of minerals, as verified by my hiking partner who bravely took a sip, and I’ll admit I would have loved to of taken a dip had it been earlier in the day.

 

This llama was hanging out on the side of the caldera as we hiked back up.

This llama was hanging out on the side of the caldera as we hiked back up.

 

After our hike we visited one of the small shacks that served food.  We had coffee and struck up a conversation with one of the locals.  My companion asked a lot about how the village had changed since his last visit and I asked a lot about life in Quilotoa.  We learned that people are getting married much earlier now than they had previously- now sealing the deal as early as 14 or 15.  We learned about their marriage traditions (BIG parties) and that most people have about 8 children.

 

The clothing of the native people living in Quilotoa was notable different from that of the people living in Otavalo, which makes sense since the weather is much more severe.  Hats are popular for both genders in both locations, though the preferred style is quite different in each place (and I noticed that many of the hats were adorned with peacock feathers in Quilotoa, a style I hadn’t noticed in Otavalo).  I also noticed that while most women in Otovalo wore flats, all the women in Quilotoa wore heels.  When I asked the guy about this he replied in Spanish that “they just like it… though it does make them too tall”.  We spoke to everyone in Spanish, but the local language in Quilotoa is another dialect of Kichwa.  We were told that they can understand the dialect from Otavalo, but that it’s different.

 

We had a great time chatting with this gent.  As we drank coffee in the corner, women cooked dinner on the burners behind us while men played cards.

We had a great time chatting with this gent. As we drank coffee in the corner, women cooked dinner on the burners behind us while men played cards.w

 

I asked about childbirth for the local women and was told that some chose to have their children in hospital while others give birth at home with midwives.  During my time in the Andes I was struck by the prevalence of nail clubbing.  This is one of those things that medical students learn about in med school, and rarely see (I had a couple patients with clubbing in my clinical years).  The condition was prevalent amongst people that I saw in a number of places in Ecuador (I pathologically started staring at peoples’ hands), and I started to wonder if there was a genetic predisposition in these populations or if it was a result of life at altitude (it’s a condition associated with chronic hypoxia).  Just a random observation that I would love to explore further: you can take the girl out of the lab, but you can’t take the scientist out of the girl!

 

There is a trail, the Quilotoa loop, that goes around the lake.  It takes about 5 hours and is apparently quite challenging.  We would have loved to tackle it, but unfortunately we had to get back on the road by midmorning the next day, so we only had enough time to head out-and-back along one side of the loop for a couple of hours in the morning.  The views were stunning, and I hope to get back one day to hike the entire loop.

 

One of the many beautiful views from the loop.

One of the many beautiful views from the loop.

 

And this is what you see when you look out the other way.

And this is what you see when you look out the other way.

 

From Quilotoa there is one bus a day to Latacunga, but you can easily catch a local taxi to the nearby town of Zumbahua at any time.  From Zumbahua busses run much more frequently or you can catch a ride with someone heading to the city and provide them with some extra pocket money.  That’s what we did, as we were quickly ushered into the cab of a small truck as we headed towards the bus.  At the end of the trip our driver asked for $2 or $3 total (I think it would have cost us about $3 on the bus), having got us there in record time (I was holding on with white knuckles to anything I could get my hands on as we sped around tight mountain curves.  While I was having multiple minor panic attacks my companion happily chatted to our driver- he’s used to this mode of transportation from when he travels home to see his parents in another part of the highlands).

 

Speeding down twisty mountain roads in the front of a truck had me grabbing on for dear life...

Speeding down twisty mountain roads in the front of a truck had me grabbing on for dear life…

 

These are typical houses for the area around Quilotoa.

These are typical houses for the area around Quilotoa.

 

From Latacunga we caught a bus back to Quito, and again headed to Plaza Foch to find a hostel.  That evening we took a walk through colonial Quito, which was lovely.  Quito was colonized by the Spanish in the mid 1500s, and as such has a lot of history.  Of note, we visited La Iglesia de la Compania de Jesus, aka la Compañía, where we had a tour and caught part of a baroque concert of sacred music (it’s always interesting to visit religious places during holy week!).

 

One of the many beautiful colonial period building lit up in Old Quito.

One of the many beautiful colonial period building lit up in Old Quito.

 

The following day I explored Quito alone, visiting the botanical gardens in Parque Carolina and reading a book and people watching in Parque El Ejido.  I also got to meet up with a friend of a friend who is a native of Quito, and I really enjoyed getting a different perspective on life in Ecuador, especially hearing a different take on the current president (talk of Rafael Correa stirs up strong feelings in many Ecuadorians I spoke with).  In the evening I headed to the airport, and sadly left Ecuador behind.  I certainly hope to return again soon!

 

There are a couple of general things that I think are worth noting…

 

Coffee, Bananas, and Chocolate- I’ll admit that I was excited to return to a country that is well known for these three delicacies.  I’ll also admit that I was somewhat disappointed by the lack of these things in Ecuador.  I don’t know if all the bananas are exported (they are a major source of revenue for the country), but I ate more bananas in the airport lounges to and from Ecuador than I actually did in the country.  There was plenty of other fruit, but bananas weren’t plentiful (at least not at this time of the year).  Likewise, with the exception of El Quetzal chocolate in Mindo, I didn’t see any good Ecuadorian chocolate.  Manicho, the quintessential Ecuadorian chocolate, is a milk chocolate and peanut candy bar, and while that was prevalent I did not see any dark chocolate for sale to the public.  While Ecuador produces high quality chocolate beans, it appears they are sent out of the country to be processed and turned into expensive Swiss (or Belgian or whatever) chocolates.  Likewise coffee is a major export for Ecuador, yet the coffee section in the supermarket I visited was an abomination of Nescafe and instant coffee!

 

Coffee selection- Are all the good beans exported? Where’s that delicious Ecuadorian coffee I was looking for?!

Coffee selection- Are all the good beans exported? Where’s that delicious Ecuadorian coffee I was looking for?!

 

Food- The food in Ecuador was generally outstanding. By far the best of any of the countries I have visited in the last few months.  The ingredients are fresh, food is simple, and food is a central part of community and family structure.  People eat out a lot, but at simple places that are serving one of two basic ‘dishes of the day’.  Some of the best meals I had cost a couple of dollars and consisted of rice, potatoes, and meat.  Ecuadorians also really love soup, and the soups that frequently preceded our main dishes were generally outstanding.  With the exception of strawberries after one lunch, desert did not seem common.

 

This plate of Menestras (beans or lentils) with pork cost me ~$3 just around the corner from the pricey Plaza Foch.

This plate of Menestras (beans or lentils) with pork cost me ~$3 just around the corner from the pricey Plaza Foch.

 

Potatoes are frequently served for lunch and dinner. They're a traditional crop, and there are varieties that  grow in the harsh Andes climate. They look quite a bit different to what you get in the store in the US!

Potatoes are frequently served for lunch and dinner. They’re a traditional crop, and there are varieties that grow in the harsh Andes climate. They look quite a bit different to what you get in the store in the US!

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Corn generally looks quite a bit different as well.  I don't think Monsanto had anything to do with these ears!

Corn generally looks quite a bit different as well. I don’t think Monsanto had anything to do with these ears!

 

Street food was common, cheap, and delicious.  I generally break a lot of the “food safety” rules when traveling, and I very happily ate food from street vendors while in Ecuador.  Common options are grilled plantains with cheese and mango with salt.  Fruit is commonly sold in plastic sleeves as snack food, and you can usually get a bag of grapes, apples, pears, citrus, or rambutans for $1 a bag.  At one point I saw Avocados being sold on the street at 10 for $1.  Not exactly your typical street food, but what a bargain!

 

Plantains grilled on the street.

Plantains grilled on the street.

 

Maduros con queso- sweet plantain with cheese.

Maduros con queso- sweet plantain with cheese.

 

Green mango with salt. Another popular street food.

Green mango with salt. Another popular street food.

 

Rambutans- A curious looking fruit!

Rambutans- A curious looking fruit!

 

Rambutans- I hadn’t had these before, but they are very tasty!

Rambutans- I hadn’t had these before, but they are very tasty!

 

 

Bags of fruit were also commonly sold on the bus, as were ice creams, chips (plantain, potato, and cassava), peanuts, and all kinds of snacks.  At various bus stops vendors would hop on the bus toting their wares, hoping to make a dollar or two before hopping off at the next stop.  You could even get whole meals sold in this way, such as fritadas sold in little plastic bags with wooden forks.

 

Juice-fresh fruit juices, or “jugos naturales” are very popular and often included as part of a meal.  Common flavors are blackberry, pineapple, naranjilla, guanabana (soursop), and tree tomato.  They’re frequently sweetened, but you can ask to have them with minimal or no sweetening.

 

Tree tomatoes, aka Tamarillos- Solanum betaceum.

Tree tomatoes, aka Tamarillos- Solanum betaceum.

 

Money- Ecuador has used the American dollar as currency since 2000.  I used more $1 coins during one week in Ecuador than I have in my entire lifetime in the US.  Things in Ecuador are cheap, so small bills are preferred, and people frequently ask you for small and exact change.  In addition to the US bills and coins, there are also Ecuadorian coins that correspond to the nickel, dime, and quarter.

 

Transportation- public transportation in Ecuador is cheap and fairly reliable.  You can traverse the length of Quito (a lengthy ride) for 25c, and get most places by bus or taxi for very reasonable prices.

 

I usually just relaxed and watched the scenery go by as we rode the bus, but from time to time I would do some light reading- such as this article on the prevalence on fatty liver in children... Longtime readers will understand my interest in this topic!

I usually just relaxed and watched the scenery go by as we rode the bus, but from time to time I would do some light reading- such as this article on the prevalence on fatty liver in children… Longtime readers will understand my interest in this topic!

 

A parting suggestion: VISIT ECUADOR.  It is a beautiful country filled with generous and kind people.  The environment is diverse and fascinating, the food is delicious.  It’s easy to get to from the US, it’s easy to travel on a very limited budget, and you’ll never run out of things to see.  It’s definitely helpful to speak Spanish (or to travel with someone who does), but some of the tourists we ran into had very limited Spanish and seemed to get by just fine.

 

The Galapagos were fascinating, but I fell in love with Ecuador when I visited the highlands.  I’ve now seen two of the four regions of Ecuador, and I can’t wait to go back again… There’s so much to see and do, but perhaps next time I can make it to the Amazon!

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I always get excited when I meet a fellow student in the medical world who has an interest in evolutionary and ancestral thinking. It doesn’t happen often, but I’ve twice run into students who, by subtle hints, have let on that they think our current thoughts on health and nutrition are seriously broken. The back-and-forth as we suss out whether we’re on the same team is like an ever-escalating dance. First someone drops the line “nutrient dense food”, then the other says something along the lines of “I don’t think saturated fats are evil”, and before you know it we’re lauding the benefits of egg yolks and liver. 

 

In a culture that tends to focus on treating illness rather than preventing it, and in an environment where we’re frequently so busy trying to fix something that we don’t take the time to step back and wonder why it broke in the first place, it is refreshing to find people who like to think deeply about human evolution and ancestry when talking about health and disease. These people are rare in most clinical settings. When I find others who share these interests I generally wish I’d discovered our common interests earlier- I wish we’d had a secret handshake to tip each other off.

 

In just over a week I’m heading to Atlanta Georgia for the 2013 Ancestral Health Symposium.  There, no secret handshake will be needed to ID those who are interested in evolutionary and ancestral health, as interest in this subject is a prerequisite for attending the symposium.  I’m excited to catch up with old friends, meet new ones, and also to speak at this year’s symposium. 

 

I’ve written before about alcoholic fatty liver disease (the subject of my PhD research), and I’m looking forward to talking about the role of dietary fats in fatty liver disease at this year’s symposium (though the time slot is shared with some other interesting talks, so I’m not sure I’ll garner much of an audience).  I’m also hosting a panel of ancestrally minded physicians who will be talking about the successes and challenges of using evolutionary and ancestral thinking in their own clinical practice.  They’ll be taking questions from the audience, so if you’re in attendance come prepared- it should be fun!

 

If you’ll be at the symposium, please say hello!

 

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A good morning of Wilderness Medicine out in Canyonlands National Park,

 

 

Here’s the short abstract for my presentation:

 

Fatty liver disease is a growing epidemic in the developed world, with some estimating that over 40% of the US population have some amount of disease.  The general recommendations for those with fatty liver disease include avoiding saturated fats, though research does not support this recommendation. In fact, saturated fats have been shown to be protective against fatty liver disease with some even having a therapeutic effect. Conversely, consumption of large amounts of polyunsaturated fats that have only recently become abundant in western diets plays a key role in disease development.

 

***

Sorry for the slow rate of posts these days.  I’m reaching the end of my final year or medical school (I actually graduate in December), and while fourth year clerkships aren’t nearly as arduous as those undertaken as a third year medical student, all the other loose ends of medical school are piling up on me at the moment. I take the Clinical Skills portion of the boards next week, the Clinical Knowledge portion of the boards at the beginning of September, and I have to get my residency applications ready to go in the near future (which, of course, includes figuring out WHERE I want to submit applications to!).  Of course I also have a presentation to prepare and a trip to Atlanta to plan!  I have a long list of things I want to write about, but at the moment other things are taking precedence.  Thank you for your patience! 

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Happy Fourth!

Happy Fourth of July to my American readers! I hope you get some rest, relaxation, socialization, and good food today!

 

I’m off to a friend’s BBQ where I’ll be partaking in lots of smoked pork shoulder and BBQ’d beef cheeks. I’ll be contributing towards dessert: red, white, and blue, of course!

 

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New Jersey has a reputation for being industrialized (or people associate “the shore” with all of NJ), but there’s a reason it’s called the Garden State!

 

Thanks for the comments (on the blog and on facebook) on the recent mammography posts- I’ll get back to them soon!

 

 

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OK- enough (for now) of the photo documentation of my past month of explorations!  While I am keen to write more about the environment, wildlife, and general experience of my last month in Utah, it’s time for me to get back to the reality of a med student and think (and write) about medicine.

 

A number of schools (and programs) offer Wilderness Medicine electives for medical students, but I chose (and was fortunate to get a spot in) the elective offered by UMass Medical School.  A few things drew me to this program.  First- it has been running for 20 years, so I initially suspected they were doing something right.  Second- many Wilderness Medicine courses are taught in classrooms with field trips and forays “into the wild” for practical experiences.  The UMass course is taught in the wild. With the exception of our first day of lecture, conducted in a hotel meeting room, all our lectures were done outside on snow, in boats, on beaches, or sitting in the desert.  Thirdly- we got to experience three different environments in the course of three weeks.  A few other courses are taught in the wild, but they are taught in a single environment.  Utah gave us access to three, very different, environments (as shown in my previous posts: alpine, river, and desert).

 

This was our main classroom in the alpine section.  We'd just arrived and are taking a quick break before setting camp, but this area was left open and we would congregate here for lectures.

This was our main classroom in the alpine section. A classmate snapped this shortly after we arrived when we were taking a quick break before setting camp, but this area was left open and we would congregate here for lectures. 

 

When I initially described this course to friends and acquaintances, many suggested that this course was basically Outward Bound for doctors.  The answer, I suppose, is yes and no.  There was certainly a lot of medical learning done in this class, but we also gained life skills that will not only help us in future endeavors in the wild but will also give us confidence as we go forward in our medical careers.  Broadly, it taught us to have confidence in our decisions and to use what we have available to do the best that we can.  I’m unlikely to ever have to improvise a splint in the Emergency Room, but knowing that I can, and having that confidence, will carry me and my classmates a long way as we progress to interns, residents, and one day attending physicians.

 

As you might expect, the medical topics that we covered were married to the environments and activities we were doing.  Before heading out on our first big trek we had a thorough lecture on blister pathophysiology, prevention, and treatment. Once in the alpine, we promptly learned about hypothermia, and how to create a hypowrap to help someone with hypothermia.  We learned about frostbite and non-freezing cold injury, as well as thermal burns, sunburns, and sun blindness.  While in the mountains, we also discussed various problems that occur at high altitude.

 

A lot of injuries in the wild are orthopedic, so we had multiple sessions on splinting, immobilizing, and caring for these injuries.  We also learned various lifts, rolls, and carries, utilizing minimal equipment- since you don’t always have a backboard and a team of people to help you.  Along those lines, we learned just how difficult it is to litter carry someone out of a bad situation (you need about 18 people to go 1 mile, and it will take you a LONG time).

 

It's not what you would do in a hospital setting, but how do you get someone with a potential cervical-spine injury free after you’ve just dug them out of an avalanche slide? Stabilize their neck with their arms and drag them! (And kudos to our instructors.  Not only did they dig a deep snow cave for us to locate with avalanche beacons, but one of the brave residents agreed to be buried down there for one of our “scenarios”. I wish I could have seen the look on my face when we realized there was a person 5 feet under the snow!)

It’s not what you would do in a hospital setting, but how do you get someone with a potential cervical-spine injury free after you’ve dug them out of an avalanche slide? Stabilize their neck with their arms and drag them. (And kudos to our instructors. Not only did they dig a deep snow cave for us to locate with avalanche beacons, but one of the brave residents agreed to be buried down there for one of our “scenarios”. I wish I could have seen the look on our faces when we realized there was a person ~5 feet under the snow!)

 

 

The slope that we dug our patient out of- the instructors made the scenarios very realistic while keeping everyone safe.

The slope that we dug our patient out of- the instructors made the scenarios very realistic while keeping everyone safe.

 

Injuries in every settings... here I’m sporting a mid-humeral splint fashioned out of a camping chair (in the rain and on the river).

Injuries in every settings… here I’m sporting a mid-humeral splint fashioned out of a camping chair (in the rain and on the river).

 

A number of dermatologic conditions occur in the wild, so we discussed their various etiologies.  We also discussed methods of wound management, including wounds caused by snakebites, insect stings, and mammalian injury.  (On that note, during our time in the desert our group spotted rattlesnakes, scorpions, and a black widow spider.)

 

A trio of beasties spotted on our trip.

A trio of beasties spotted on our trip.

 

Many of the topics we covered are much more likely to be encountered in the wilderness than in a clinical setting, but some topics are ever-present in any setting.  Anaphylaxis and allergies can occur at any time, and while you may acquire tick-borne illnesses or infections diarrhea in the wild, the incubation time for many of these mean that they frequently present at a primary care office.  Nonetheless, these were topics we covered on this course, frequently harking back to the “bible” of wilderness medicine: Wilderness Medicine written by Paul Auerbach.

 

Thus far I’ve mainly focused on the didactic portion of the course, but much of the learning took place in “scenarios”.  I’ve never participated in simulation medicine, save for the standardized patients we get on our OSCE (Objective Structured Clinical Exam) at the end of most clerkships. While at first it can be awkward to “practice” medicine on people that you know are acting, once you get into the part it is a wonderful way to learn.

 

The beauty (and perhaps the terror?) of our scenarios was that our instructors would let us “play it out” in the field.  In clinical settings, while students may participate in discussions about patient care, they are never in the driving seat.  In our wilderness scenarios we were allowed to make the decisions and deal with the consequences.  At times this was frustrating (can’t I just ask the Wilderness Fellow standing over my shoulder what I should do), but it also allowed me to make mistakes that will stick with me for years to come.  For example, if a “helpful” stander by hands your patient some food, make sure they’re not allergic to it before they take a bite (that’s how a painful case of sun blindness can progress into life threatening anaphylaxis).

 

The scenarios also allowed (or I should say made) students make decisions about evacuation. Do we evacuate the patient? How? Can they walk? Do they need a litter? Do they need cervical-spine protection? Do we leave now or hunker down for the night and head out tomorrow? What’s the best evacuation route? Could a rescue team get a helicopter in here? A snowmobile? Maybe we should send runners to a ranger station? Where’s the closest location we can get cell phone reception?

 

The scenarios progressed with our wilderness medicine knowledge, as well as our knowledge of Incident Command Structure (ICS).  There were twelve medical students in our class, and when we had a scenario with one patient, it would be easy to have “too many cooks in the kitchen”.  On the other hand, when we had three patients, we could quickly run out of hands as people were relegated to “safety officer”, “equipment”, “communications”, and if the scenario necessitated it “runners” leaving the scene to make contact with civilization.

 

All in all, the medical education side of this course was excellent.  Some of the medicine was a review, but it was a much-needed review and one that frequently found we students (who are trained to practice medicine in well-stocked hospitals with multiple imaging modalities at our fingertips) asking “what do we have that we can use” and “how can we do what we need to get done”.

 

Medically, this class was a reminder of quite how much we’ve learned about medicine in the last few years.  It also emphasized that frequently there is no “right way” to handle a situation and your best guess and best efforts may save the day. We were also reminded of the reality that sometimes there is nothing you can do to save a life… and that is an important lesson to learn as well.

 

 

Not a bad place for a lecture...

Not a bad place for a lecture…

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Truth in Fiction

A few months ago I did a two-week elective with our hospital’s Emergency Medical Services. Over those two weeks I saw all manner of medical “emergencies”.  Some were true emergencies, but plenty were BS calls where first responders and ambulances were called into action when what was really needed was an $8 taxi ride to the emergency room (or even better, $8 worth of broth and a couple days in bed to get over the flu, but I digress).

 

I met some wonderful first responders on this rotation. People that really want to help others and who obviously get a high from the adrenaline of being called to duty in an emergency.  As I saw bits of the recent Boston and Texas events unfold I imagined how the EMTs and medics I worked with would have jumped to duty in these situations.  Indeed, many of them did 11.5 years ago when they responded to the attacks on the World Trade Centers.  One of the women I worked with lost a friend who was responding that day.

 

Unlike the hospital environment, where people usually avoid any controversial conversations, I frequently found the topics of religion, politics, taxation, healthcare reform, and gun-control being discussed. The disagreement was sometimes vehement, and the conversations often heated, but there were never any hard feelings at the end of the day.

 

I worked with a number of EMTs and medics on my 2-week elective, but I bonded with one in particular. I think we had matching (or perhaps complementary) streaks of cynicism and optimism (yes, you can be both a cynic and an optimist. In my case, I think my cynicism protects my optimism from being snuffed out by reality).  He asked if I had read The House of God [1], by Samuel Shem, (the nom de plume of psychiatrist Stephen Bergman), and when I said I had not he insisted that I must.

 

I ordered the book right away, but like so many excellent book recommendations, it took me a while to get around to reading it.  I finally started a couple weeks ago, and quickly devoured the whole book.

 

The House of God is a satirical novel that portrays the life of a medical intern in the early 1970s.  A lot of things have changed for interns since this book was published- the most notable (for the sake of this novel) is work hour restrictions. Nonetheless, there is much about this novel that made me, even as a mere medical student, laugh, cringe, and nearly cry.  I have since recommended it to many other medical students and residents with the description that it is “brilliant, hilarious, and terrifying”.

 

The book is, of course, fiction, but it is, in essence, true.  It is as poignant today as when it was first published in 1978.

 

Some of the scenes are things that I can relate to, if not describe verbatim, from my experience as a third year medical student.  Some of the patients I have seen are the embodiment of the caricatures described in this novel. “The Yellow Man” with his failing liver, the (relatively rare) young patient who invariably has some condition we can not treat and who sadly dies, the (common) old patient that we can not treat effectively but that we can patch up well enough to carry on… These are patients I know, even though they are fictional.

 

I won’t write a review of the book- it is brilliant, and I think everyone involved in the medical community should read it. I find myself wondering what non-medical people think of the book… I suspect it would be hard to decipher satire from actuality- the line is definitely not clear, even for those who work in the medical community.

 

The House of God uses terms that are familiar to those who work in a hospital- and I’m not talking about words you find in a medical dictionary. The term “turfed” is when a patient is moved from one medical team to another (such as from a general team to a specialty team, or vice versa), a “bounce back” is a patient that your team treated who was then transferred to another team or discharged from the hospital, only to “bounce back” to your service.  The term “gomer” is one that I write with some reluctance.  It is a word that I have never heard uttered in the hospital, and have only heard in “humanism” lectures (in which it was made clear that no one should ever use the term), which describes “a human being who has lost-often through age-what goes into being a human being”.  The House of God is how this term first became well known, a term that is an abbreviation for “Get Out of My Emergency Room”.

 

The same author, again under his pen name, published a piece in 2002 in the Annals of Internal Medicine entitled “Fiction as resistance” [2], in which he describes using storytelling to illustrate, and retaliate against, the brutality and inhumanity of medical training and the practice of medicine. Fiction makes reality palatable.

 

In this article Shem writes about how he encourages people to resist the inhumanities of medicine. The keys, he believes, lie in (1) learning our trade and being aware of the world around us and our patients, (2) avoiding isolation, (3) speaking up, and (4) learning empathy. I am not sure how one learns empathy.  Sadly, some aspects of medical practice almost seem designed to dispatch it.

 

Just as I finished The House of God, my mother sent me a book for my upcoming birthday.  I’ve quickly read about half of On Call: A Doctor’s Days and Nights in Residency [3], written by Emily Transue, an internist on faculty at the University of Washington.

 

Reading these books in immediate succession is powerful.  One is satirical fiction while the other is reality, but if you changed the writing styles you could easily swap the real stories for the fiction.  Both write of the dehumanization that occurs during medical training, but Shem follows the adage “if you want to tell people the truth, make them laugh, otherwise they’ll kill you”.

 

Sometimes I think I’m too young, too “wet behind the ears”, to write about dehumanization in medicine.  I’m only a fourth year medical student, how much have I really seen.  Other times (well, most of the time), I worry that expressing my feelings, especially in writing especially on the internet, is just asking to have things I say come around and bite me at some point in the future…

 

Another part of me, however, thinks that medical students are best positioned to recognize dehumanization in medicine.  We are the least indoctrinated, the least hardened.  As students, we also know that there’s a lot we can’t do. The idea, of course, is that with training we will be able to fix people, heal people, make things better.  Sometimes we can; frequently we cannot.

 

As students, we know that we are fairly powerless in the management of a patient’s medical care.  This can be frustrating when you think there is something that could be done that might help a patient, but also leaves you in a position where you don’t feel like you’re personally failing a patient when there is little to be done (at least medically speaking).  When those with more medical clout, more medical ability, are faced with a situation where the best medicine we can offer will do little good, they sometimes have a hard time letting go.  As if saying “there are no more medical options we can try” or “this isn’t going to get any better” is admitting defeat.

 

Perhaps it is defeat. But maybe in this circumstance admitting defeat makes you better.  When you realize that you have exhausted your medical options, perhaps you can finally treat the person, not the disease.  It’s just a shame that we don’t always treat the person first.

 

1.            Shem, S., The House of God. 1978, New York, New York: Dell Publishing.

2.            Shem, S., Fiction as resistance. Ann Intern Med, 2002. 137(11): p. 934-7.

3.            Transue, E.R., On Call: A Doctor’s Days and Nights in Residency. 2005: St. Martin’s Griffin.

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Road Trip!

I have more to write about lipids and liver (consider yourselves warned!), but I likely won’t have a post out on that subject for a little while.

During the last month I have been enjoying my Family Medicine Clerkship. I am very fortunate to be working with an excellent and enthusiastic physician, with whom I have had fantastic patient interactions both in the office and on house calls (Yes, house calls- who knew physicians still did those?!). Not only is this physician an enthusiastic practitioner and teacher, but she is also very supportive of my (not so main-stream) academic interests. This was evident in the office, where she was keen to push me towards patients whose medical conditions I was particularly interested in and where she encouraged me to talk about nutrition with many of the patients (Yes- evolutionarily appropriate nutrition- not some American Diabetic Association or “My Plate” nonsense”).  This physician was also keen that I pursue my academic interests outside of the clinic, so she has worked with me and my schedule so that I can attend the 2nd annual Ancestral Health Symposium in Boston at the end of this week.

This time last year I was in the throes of writing my thesis, and I was forced to watch the inaugural Ancestral Health Symposium from the sidelines (you can watch the videos from last years symposium here). I’m very excited to participate in person this year!  (If you’re unable to attend but want to be kept up to date, you can follow the twitter feed @Ancestry2012)

While I am looking forward to a number of the lectures on offer this year, I am equally excited about catching up with other people interested in Ancestral Health.  I’ve been fortunate to cultivate a number of friendships within this community over the last couple years, though because of distance I’ve only met a couple people in person.  While I’ve come to know some quite well through the powers of e-mail, Skype, and Twitter, there’s nothing quite like some face time with friends who share (arguably very nerdy) interests.

Anyway- this is a drawn out way of saying “Hey- I’m headed to Boston for AHS 2012. If you’ll be there and want to say ‘Hi’, please do!”.

Pic- for identification purposes!

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