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Posts Tagged ‘life’

A New Year’s Update

I struggled with the title of this post for a while. It’s a long time since I’ve written anything (for the blog), and I wanted the title to be catchy, edgy, maybe even with a touch of double entendre. Alas, my creative mind has failed me. Perhaps this is a consequence of writing nothing but clinical notes for the past 6+ months- a result of being in the intern year of my medical residency. There is no need for provocative language, crafted sentences, or grammatical subtleties in medical notes. On a good day, clinical notes are composed of brief and simple sentences. On a busy day, notes are often composed largely of sentence fragments and phrases. On a bad day, notes may largely consist of abbreviations and acronyms.

Residency: Where to begin? I suppose at the beginning.

I haven’t tried this on older, more seasoned, docs, but it can be a bit of fun to ask a young doctor about the first order they ever gave as an MD. I come from a generation of medical students that did not give orders as students (I may have written out a paper order on occasion, but these were never acted upon until cosigned by a supervisor), so on July 1st, my first day of my residency, I showed up at 5 am eager (and somewhat petrified) to start my first rotation on Labor and Delivery- never having given a “medical order” to anyone. That morning, a nurse snagged me outside a patient’s room and said “Oh, she’s having some heartburn, can you write an order for Tums?”

“Sure”, I said calmly- while on the inside I felt like a deer in the headlights, trying to think of anyway possible that giving a lady Tums might lead to her demise. I stressed, I fussed, and then- as many interns do- I consulted a fellow resident. “Can I just write this lady for Tums?”

“Sure- but she should already have them ordered in the admission order set.”

How anticlimactic…

For a lot of young doctors that I’ve talked to, that first order request is for Tylenol.

The story usually goes something like this: patient’s nurse sees new resident. “Hey- Mr. Smith in room 14 has a headache. Can I get some Tylenol?”

New resident “Sure… Give me a minute?”

New resident then scurries off to the work room to check the patient’s allergies, liver function tests, alcohol history, etc, etc, etc. Resident then checks dosing, route of administration, frequency, and scans a med list wracking his brain for anything that might cause an interaction… I have heard this story many times- plus or minus a consult with a fellow resident.

That is on July 1 (or perhaps the end of June, as many programs now jump the gun on the July 1 residency start date). Hop forward a few weeks and the same resident will likely respond to the nurse “Sure- need a written order or can you take this as a verbal?”

Back to July 1: As I mentioned- I started my residency on labor and delivery. As a family medicine resident my intern year is a mix of some obstetrics, a pinch of surgery, a dose of pediatics, a healthy whack of in-patient medicine, and a sampling of various other areas of medicine (as well as a consistent stream of out-patient clinic). I started on Ob- one of the most challenging and grueling rotations in our residency. I’ll admit that I was initially scared but ultimately pleased that my medical career started on labor and delivery. My days of shadowing and standing in the background were gone. As a medical student I was allowed to stand in the room during a delivery and catch the occasional placenta, but as an intern I was expected to manage a patient from admission to discharge, with a labor and delivery in between. As my skill set and confidence grew, so did my autonomy- I was really someone’s doctor!

Of course, claiming that title was something I was hesitant to do…

As medical students, some people introduce themselves as “Student Doctor So-and-so”. I found this verbiage absolutely ridiculous, and instead went with the line “Hi- I’m Victoria, a medical student on the team looking after you.” I often followed this with the pseudo-apology “I can’t write you a prescription for any of the good drugs, but if there’s something going on and you feel like no one’s listening to you, I promise I’ll listen.”

Back to July 1- Do I actually introduce myself as “Doctor”? Who do I think I’m kidding?!

Folks, I’m here to tell you that the “Imposter Syndrome” is real. On July 1, there was no way I was introducing myself as “Doctor”. Instead, I modified by student script and said “Hi- I’m Victoria- one of the residents on the team looking after you.” I’m pretty sure I never introduced myself as “Doctor” that whole first month.

For my second month of residency I moved to a community hospital where I was doing in-patient medicine. There, my attending physician (my supervising physician) heard my introduction and said “Your life would be much easier if you introduced yourself as ‘doctor’”. Innately, I hate this reality. Despite working hard for many years to earn a slew of letters after my name, I’m not comfortable with the reality that saying that gets me more respect.

I battled on for a day or two, with my attending introducing me to patients as a doctor and hissing over my shoulder “doctor”, when she heard me call the lab, introduce myself as Victoria, and then sit on hold for 5 minutes waiting for a result. It didn’t happen quickly, but bit by bit, either by repetition or by the slow growth of the belief that maybe- just maybe- I was actually “doctoring”, I started to become comfortable with the term. I frequently couch the introduction with “one of the residents”, but I’m now comfortable introducing myself as Doctor, and have even found myself briefly annoyed when someone introduces me to a new patient by my first name. Outside of a patient’s earshot I have no need for a title (unless it bumps me to the front of the line when calling in to make an appointment for a patient or if I call in for a lab result), but I’ve come to learn that while the title doctor may give you respect, it also gives your patient confidence in you- and that is something incredibly valuable.

And what of Evolutionary Medicine and Ancestral Health?

If you’ve read many of my old posts (save those on travel), you’ll know that I have a passion for evolutionary medicine and ancestral health. One of the reasons I chose the residency program I did was because I knew it was a place I could explore those interests. That being said- my ability to explore and practice that kind of medicine has been quite limited. In my 8 weeks of Ob I had 49 vaginal deliveries: not one of which was done in a non-conventional position. I’ve probably prescribed more probiotics than most, though how much good a bolus of pure Lactobacillus does in a gut that has been firebombed with antibiotics I’m not really sure. (Strangely people rarely seem interested in eating Kimchi to replenish their gut flora… )I’ve also probably prescribed as much Tylenol as everyone else, despite believing that fever is a symptom (and a useful infection-fighting one at that) of illness and not something that needs to be treated in-and-of-itself. I’ve had small victories, discussing the potential benefit of fevers with some patients and families, and having them agree that they don’t need or want their fevers treated unless the discomfort is such that they can’t sleep or rest. I’ve also had these plans thwarted by covering residents and nurses who can’t stop their desire to “fix a number” and “fix a fever”.

Clinic is a bit of a different picture. There I’ve recommended, sleep remediation (sans medication), exercise, and books such as “It Starts With Food” to a number of patients, and been pleased to have the occasional one come back reporting success with lifestyle intervention. I’ve also had occasional welcome surprises, as I meet new patients who (sensibly) CrossFit or embrace a high-saturated fat/whole food diet who usually look shamefacedly at their doctor saying “My family wants me to come see a doctor because they know you’ll tell me this is a bad idea…”. Connecting with those patients- ensuring proper rest in one, recommending Kerry Gold Butter to the other- is an unexpected but welcome pleasure.

6+ months in…

I’m 6 and a half months into my intern year of residency. I have worked harder, put in more hours, and been more stressed than I ever have been before (the stress of writing a PhD thesis was quite different). Having written (and then retracted, since it was a duplicate order) my first order for Tums, I have gone on to write hundreds more orders. I still get nervous with firsts, but my comfort level is rising. Yesterday I did a thoracentesis for the first time. One day I will inevitably run my first code- this thought terrifies me.

I have also made some wonderful connections- with fellow residents, nurses, and patients. I continue to believe that doctoring is about people, not just illness, and while some patients come through as just another case that is quickly gone from my mind once the discharge is dictated, others have forever shaped who I am as a person and a doctor.

And Utah- oh Utah. There is not a day I have regretted moving to this state or choosing this residency program. I work with great people who love what they do but also value having a life outside of work. I work hard, but have the opportunity and ability to play hard as well. In the longer days of summer I was taking evening hikes some nights after work. With a tank of gas and some motivation I’ve been able to put 1-day weekends to good use, and have explored many of the national and state parks. Now that winter has come, I’ve used my rare day off to take to my cross-country skis, and am in the process of rediscovering my downhill ski legs, having hit the slopes for the first time in 13 years.

So here I am- half way through my first year of residency. I’m a doctor, and I no longer feel like a fraud when I say that. Many of my academic interests have been put on hold, but I have faith that I’ll be back to them as time allows. I’ve learned a lot since I moved to Utah in June: about medicine, myself, and others. There is so much to learn, so much to think about, and so much to explore, in medicine, wilderness, and life!

Little Cottonwood

View from Little Cottonwood Canyon, near the summit of Pfeiferhorn.

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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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Thanksgiving

There are so many things that are worth writing about on and around Thanksgiving. 

 

For those of us interested in ancestral health and evolutionarily-appropriate eating it’s fun to explore what a pre-pilgrim Thanksgiving feast might have been.  Yesterday I spotted this article on Twitter discussing what a pre-pilgrim dinner would have looked like in Portland (the location of my penultimate residency interview!).  It is well worth a read.

 

My Thanksgiving feast this year is certainly of the ‘more traditional’ pilgrim/post-pilgrim variety, and will consist of a locally raised wild turkey and a Bourbon Red – a heritage breed turkey.  Incidentally, I don’t expect any Wild Turkey Bourbon will be consumed…

 

Thanksgiving is also a great, and thoroughly appropriate, time to talk about what we are each thankful for.  Family, friends, food, shelter, health; even the ‘least fortunate’ amongst us in the developed world are incredibly blessed when we look around the world and see those without access to clean water, basic medical care, or basic freedoms and security.

 

As I reach the end of my med school career, and pathologically over-think my future options, it seems like a very appropriate time to look back and think about what I am most thankful for from this rather lengthy journey.  Without a doubt, the thing I am most grateful for during the last 8.5 (*gulp!*) years is people.

 

As some of you may know, it was never my intention to be a doctor.  Truth be told, I never would have taken the MCATs (Medical College Admission Test) if my summer roommate hadn’t dared me to do it.  Nipa, though you won’t be reading this, Thank you.  On the day that I took the test I met a charming and chatty pre-med while we waited in line.  She thought my light-hearted approach to the MCAT was hilarious and offered me her AIM screen name so we could chat if I decided to apply to med school.  Without Jackie my AMCAS (American Medical College Application Service) application would have been submitted sans-personal statement, an act that certainly would have doomed my efforts.  Incidentally, Jackie and I ended up attending the same medical school, so I’ve had the opportunity (even as recently as a couple of months ago, since she pursued residency training locally) to express my thanks to her.

 

My large university had a “Pre-health” office that assists aspiring health professionals prepare their application for medical school.  When I called to ask if they would help me (only a month or so before applications were due), they told me that they could help me get my application ready… for the next year.  Fortunately the pre-health office at the woman’s college campus was willing to take me on (despite the fact that I wasn’t from her college), making my application to medical school a reality.

 

The day before my first medical school interview my college roommate asked me what I was planning to wear for my interview, telling me “I think people wear suits for med school interviews.”.  I laughed this off, but after a last minute email exchange with my advisor my roommate went shopping with me to help me find an appropriate suit.  I alternate between cringing and chuckling when I think about the response I would have received had I shown up to a med school interview in a tank top and cool Malaysian Sarong, my original plan!  Incidentally, prior to my residency interviews I headed to Long Island to meet up with this same friend for another suit-shopping experience (this suit is much sharper, if I do say so myself!).

 

I applied and interviewed for more PhD programs than I did MD/PhD ones (though since I only interviewed at four PhD programs that’s not saying much!).  I was very tempted by two of the stand-alone PhD programs, and my decision to pursue the combined degree literally came down to the final day.  I remember the day before the decision was due I met with an MD/PhD student who sold me on the virtues of a combined program.  Without Jay, it’s entirely possible I would have opted for a non-clinical route.  Another good friend, who’s opinion I still very much value, had warned me that “No sane person puts herself through the torture of med school unless she’s sure she really want to be a doctor.”.  I’m not saying he’s wrong- I’m sure there’s quite a list of people who have questioned my sanity over the years!

 

Someone who has contributed more to my medical education than he shall ever know is Russell.  I thank “Russell”, though I shall never know his real name.  Russell was a 74-year-old man who died of “coronary artery disease”, at least that’s what his cause of death was listed as.  While I became very familiar with his body, I will never know anything about his life.  From his lean and muscular body (Russell was short for “Russell the muscle”), I imagined him as a fit and active man, but I shall never know.  Books have been written about gross anatomy lab (including one written about the experience at my school- my anatomy teacher is on the cover of this book!), and I’m sure every student has a slightly different experience of this ‘right of passage’.  I feel safe saying that we are all, uniformly, thankful for the gift that our donors gave.

 

I’m not going to go through and thank all the people who helped me survive (I would not call it thrive) in medical school.  Completing my PhD was a particularly stressful time, and I am forever thankful for the many people who supported me through that experience.  Returning to medical school (after 4.5 yrs in the lab) was difficult, but made much easier by classmates who did their best to get me up to speed on the floors.  The three guys I did my first neurology rotation with were particularly kind in helping me hold-it-together while stressing out about how to present a patient to our attending physician for the first time.

 

I would be remiss for not recognizing the role that many of my residents played in my development as a future physician.  Some residents love to teach while others barely tolerate students, but even the grumpiest and most sleep-deprived resident shaped my experience in someway (for better or worse).  Likewise, various attending physicians have been mentors that I struggle to recall while others have truly fashioned some aspect of my clinical or personal development.

 

It takes a village to raise a child, but it takes a hospital to make a doctor.  When you are a medical student or resident-physician, nurses, physician assistants, therapists, and social workers can make or break your day.  The reality is that these people frequently know more than you about what your patient actually needs.  Speaking of patients- they are, of course, an integral part of medical education.  Many are lost in my memory, but others will stay with me throughout my clinical career, for the impact they had on my medical knowledge and the impact they had on me personally.

 

As important as all of these people have been to my development as a clinician and a person, I am most grateful for my friends. I have loved the poem “A Prayer” by Frank Dempster Sherman (1860-1916) since college, and as I travel around the country interviewing for residency programs (and catching up with friends along the way), it has never struck so true.

 

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I have a fantastic network of friends, one that I am truly thankful to have nurtured over the years.  In an era when the word “friend” may conjure up thoughts of a virtual connection on facebook (especially when in the same sentence as the word “network”), it can be easy to lose touch with people that matter or let friendships devolve into a series of “likes” and “pokes”.  On the other hand, online social networks can help make connections that have been lost.

 

When I interviewed in Vermont I met up with a friend I have not seen since High School. On my way home from an interview in New Hampshire I spent the weekend catching up with friends in Boston. Before heading to Colorado for an interview I went to play polocrosse (imagine a combination of polo and lacrosse) for the first time in 2.5 years, in Texas.  There I saw friends that I have literally not seem for years, but who opened their homes and stables to me without hesitation.  With the exception of one upcoming interview, all of my interview travels are combined with a visit with one or more friend.

 

When I entered medical school I was unsure whether I would ever use my clinical degree in practice.  The medical knowledge would be useful for asking relevant research questions and the clinical knowledge would be useful when friends and family needed phone-a-friend medical advice, but I certainly was not sold on the idea of being a clinician when I entered medical school.

 

Now I am sold- I do want to practice clinical medicine (as well as be involved in research and academics), and I am forever grateful to all the people who have helped me find my way along this path.  My desire to be a fount of knowledge for my friends and family is still one of my greatest drivers, and it is certainly a large part of why I have chosen to pursue family medicine.  I’ve been warned many times that friends and family make the worst patients- they’re notorious for not listening to someone they’ve known since “way back when”. That’s fine- I really am OK with that (just keep your griping to a minimum when your low-fat, low-cal, low-“food” diet fails to leave you feeling great.). I do hope, however, that when my friends do need me, I can live up to the last line of that fantastic poem.

—————–

Oh, and if you’re curious, this is polocrosse.  Check out americanpolocrosse.org for more info. 

Playing this horse (Cripple Gray Zeta) was a privilege and a thrill. Thank you, thank you, Susan and Paul!

Playing this horse (Cripple Gray Zeta) was a privilege and a thrill. Thank you, thank you, Susan and Paul!

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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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I’ve been hesitant to write this post.  This blog is certainly not a travel blog, and it was never intended to be a place where I posted my exciting travels (and to be honest, during the final years of my PhD and third year medical school I didn’t really have any exciting travels to write about).  That being said, I can’t help but post about my adventures in Moab.  If my antics encourage just one person to get outside and enjoy time in the great outdoors, I will consider this post a huge success…

 

Moab…

After completing my Wilderness Medicine Elective, I opted to take two weeks of vacation time (4th year medical students can get a rather absurd amount of vacation time if we play our cards right) to recoup, relax, and since I was already out west, spend time in Colorado with my best friend.  With over 100lbs of luggage to lug around, I managed to sweet talk my best friend into picking me up in Salt Lake City (where my elective wrapped up), instead of hopping a plane to Denver.

 

My best friend is a good sport about road trips (I suppose she should be, as I once drove 28hrs straight with her when she moved cross-country to Colorado), and she was happy to come pick me up, suggesting that we route our trip back through Moab for a bit of outdoor adventuring before heading back to Colorado.  I didn’t know much about Moab before I got there, but I knew Arches National Park was right next door and that the desert portion of my course was in Canyonlands National Park, so I thought it might be fun to swing back through and at least check out Arches on our way back.

 

That was before heading west… Once I met and talked with the river guides who work out of Moab and spent a “transition” day there between the river portion and the desert portion of the Wilderness Medicine elective, I was counting down the days until I would be back.

 

Moab is a stunning place- the rock formations and geology surrounding the town are truly “other worldy”, with the red rock shaped by time and weather into precarious and beautiful structures.  There is also a LOT to do in Moab for people who enjoy the outdoors.  The Colorado River can be enjoyed from rafts, boards, boats, or the shore, there seems to be a new hike for every day of the year, biking (mountain and road) is king, and the weather in May is wonderful for camping (sans-tent, for those-like myself- who are so inclined).

 

There are plenty of places to stay in Moab, but being on a budget and having spent the majority of the prior 3 weeks sleeping outdoors, I was more than happy to camp in Moab.  There are many campsites with RV hook ups, tent sites, and amenities such as showers, but I’m a fan of primitive camping.  Fortunately, for those in the know (or those who get the scoop from knowing river guides), there is plenty of dispersed camping to be had in spots around Moab.

 

view from one of our camp sites up off Klondike Bluffs, about ten miles north of town.

The view from one of our camp sites up off Klondike Bluffs, about ten miles north of town.

 

We spent out first morning in Moab getting coffee (“That Paleo Guy”, Jamie Scott, would swoon at all the coffee spots in Moab) and sorting out plans for the next couple days.

 

Wicked Brew- home of a mighty fine shot of espresso

Wicked Brew- home of a mighty fine shot of espresso

 

After a morning in town we headed out for a hike at Fisher Towers.  This hike, while popular, is a bit off the beaten track (at least in comparison to the tourist heavy hikes in Arches National Park).  The rock formations are stunning and the plant life was beautiful. This place is popular for rock climbers, and it was breathtaking to see them atop the tallest towers.

 

Fisher towers- if you go on this hike, make sure you get on the proper trail… we ended up scrambling quite a bit looking for a trail on various dead ends when we erroneously got started on a “photograph trail”.

Fisher towers- if you go on this hike, make sure you get on the proper trail… we ended up scrambling quite a bit looking for a trail on various dead ends when we erroneously got started on a “photograph trail”.

 

“The Titan” is the tallest structure at Fisher Towers, and is very striking.

“The Titan” is the tallest structure at Fisher Towers, and is very striking.

 

 

Alas, I seemed to have a knack for attracting rain on this trip… As we rounded the turn at the top of the hike, we were greeted by storm clouds and a flash of lightning.  Needless to say, we made a rapid retreat (I did learn about lightning strikes on my Wilderness Medicine course, but like almost all aspects of medicine, the best solution is prevention, prevention, prevention!)

Alas, I seemed to have a knack for attracting rain on this trip… As we rounded the turn at the top of the hike, we were greeted by storm clouds and a flash of lightning. Needless to say, we made a rapid retreat (I did learn about lightning strikes on my Wilderness Medicine course, but like almost all aspects of medicine, the best solution is prevention, prevention, prevention!).

 

After our hike, we headed back towards Moab, making one stop at a local vineyard and a detour down Onion Creek Road.  If you are around Moab and have an AWD vehicle (or are comfortable taking your vehicle through multiple stream fords), definitely check out Onion Creek Road.  If you’re really lucky, one of the dispersed camping sites might be open and available (we didn’t have any luck on that front).

 

My best friend is an avid paddle boarder, and she’d contemplated packing her paddle boards down to Moab for us to use on the Colorado River.  It seemed that renting boards in Moab was a much better option, so after making some inquiries, we ended up renting two inflatable boards (Badfish MCIT) from Canyon Voyages, strapping then to our car, and driving them up river to our drop-in point.  We’d scouted the river the day before and had decided to drop in at Take-out beach and to get out at Lion’s Park: a ten-mile paddle downstream (with my friend opting for the hitchhikers shuttle after parking her car down at the pull-off site. Pro-tip: carry your PFD (personal flotation device) and catching a ride is pretty easy).

 

Boards- Ready for adventure.

Boards- Ready for adventure.

 

While a road parallels the Colorado River the length of our ten-mile paddle, the trip was still very calming.  I’ll be honest- I went through our lone rapids and a couple of the choppy fast-water sections firmly on my knees.

While a road parallels the Colorado River the length of our ten-mile paddle, the trip was still very calming. (Though I’ll be honest- I went through our lone rapids and a couple of the choppy fast-water sections firmly on my knees.)

 

The rest of our day was spent driving out to Dead Horse National Park, seeking out dinosaur footprints (yes really), cooking dinner at our campsite, and then meeting up with a new friend from my Wilderness Medicine Elective- one of the river guides from my travels down Desolation Canyon.

 

I can’t tell you if they’re Therapod or Sauropod footprints, but they were pretty cool!

I can’t tell you if they’re Therapod or Sauropod footprints, but they were pretty cool!

 

As much fun as the previous two days had been, the real adventures began when we started hanging out with a local… My river guide friend was just back from another long trip down Desolation Canyon, which meant that he had a bit of time off before heading back to the river.  The next morning he took us on a hike up to Cable Arch, an arch off the beaten track on an unmarked trail.  Our drive out to the trailhead took us past quite a few petroglyphs, including one that I found very interesting.

 

The birthing rock- my picture isn’t the best, but this petroglyph seems to show a breach position birth.  Some readers may remember that I’m interested in “traditional” positions for giving birth, so I found these depictions particularly interesting.

The birthing rock- my picture isn’t the best, but this petroglyph seems to show a breach position birth. Some readers may remember that I’m interested in “traditional” positions for giving birth, so I found these depictions particularly interesting. (Here’s a better picture.)

 

An arch all to ourselves… something you seldom get in Arches National Park

An arch all to ourselves… something you seldom get in Arches National Park

 

Not another person for miles...

Not another person for miles…

 

Scrambling up and down rock faces is a lot of fun (and an excellent work out)…

Scrambling up and down rock faces is a lot of fun (and an excellent work out)…

 

After a relaxing lunch in town, we headed up to the Sand Flats for an afternoon adventure of rappelling.  I’ve never been rappelling (save for the ~15’ rappel we played with up in the alpine on the Wilderness Medicine course), and I’ll admit that at the top of our first descent I was more than a little nervous.  However, as I lowered myself into the slot canyon (into an area aptly named “the medieval chamber”), my fear was replaced by exhilaration.

 

Rappelling down into the "Medieval Chamber".

Rappelling into the “Medieval Chamber”.

 

The second rappel, off a natural bridge, landed us at the focal point of a somewhat well travelled out-and-back hike.  My best friend went first, and her adventures were well documented by some of the sightseers below!

 

Kate, headed down off the natural bridge

Kate, headed down off the natural bridge

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The next day found us rappelling again, this time in Arches National Park.  We were truly spoiled to have a local show us yet another awesome spot, for while we left our car in a crowded parking lot, we quickly backtracked along the road and scrambled up a rock fall to find ourselves isolated atop a large mesa.  Hundreds of feet above the other tourists below us, we spent much of the morning relaxing above Arches, in our own world, away from any other visitors to the park.

 

Above Arches- We spent quite a bit of time wandering around the top of the mesa, but eventually we settled down to soak up the sun, talk, and relax.

Above Arches- We spent quite a bit of time wandering around the top of the mesa, but eventually settled down to soak up the sun, talk, and relax.

 

Above Arches- I’m not sure the scale comes through…

Above Arches- I’m not sure the scale comes through…

 

After an hour or so of basking on the rocks, we started our descent back down into the canyons.  This (again, unmarked) path took us down a number of small descents before finally putting us atop a 100’ wall down to the canyon floor.  The rappel was a rush.

 

Can you find me? Hopefully the scale comes through now!

Can you find me? Hopefully the scale comes through now!

 

My best friend and I did plenty of other things in Moab, including taking a drive and some hikes through Arches National Park. Arches IS stunning, but after getting an insiders-tour to some stunning and relatively unknown-to-tourists spots, hiking along crowded groomed trails to ogle at postcard views lacked some luster.  I don’t mean to sound snooty, and I hope it doesn’t come across that way, but I think my favorite moments of this trip to Moab were the moments with friends around bonfires, scrambling up rocks, and quietly taking in all that our surroundings have to offer.

 

After more than a month away, I am finally headed home to New Jersey.  I am heading home physically tired but psychologically refreshed.  I have always believed that nature is *good* for humanity, but I have never experienced this goodness so intensely as in the last month.

 

Through the wilderness medicine elective, my trip to Moab, and then a Memorial Day Weekend camping trip in the mountains of Colorado, I have experienced many different environments.  A big part of experiencing these environments, to me, is learning to be present in the moment- to quiet the mind of all the banality and drama that so easily catches us and to really appreciate what surrounds us.  In the hustle and bustle of normal life this skill takes practice, but it is practice that pays back in dividends on the principle that nature satisfies a deep and primal part of our humanity, and we should seek it out and absorb it whenever possible.

 

Memorial Day Moonrise over Twin Lakes in Colorado- Not sure I can think of a better way to end the day…

Memorial Day Moonrise over Twin Lakes in Colorado- Not sure I can think of a better way to end the day…

 

Find your people, find your places, and enjoy the moment…

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I have spent only 5 of the last 25 nights in a bed (4 different beds, to be precise). At this point I feel a touch claustrophobic in bathrooms and feeling clean is certainly a novelty.  My Wilderness Medicine elective is over and I have had an exceptional visit in Moab (more on that in another post). Tomorrow I head to the mountains of Colorado for one last stint in the wilderness before heading back to New Jersey where I will start a radiology elective on June 3rd.  From a month in the wilderness to an elective spent in dark, windowless rooms- the change in environment couldn’t get much more extreme (which is saying a lot, coming from someone who has gone from alpine camping to desert camping in the course of 3 weeks).

 

This is the final installment of “Pic of the Day”, at least for the Wilderness Medicine Elective.  I may not be able to resist a “Pic of the Day, Moab edition”… we shall see.

 

For the desert portion of the course we headed to Canyonlands National Park, specifically The Needles District of the park.  We spent 4 nights in 3 different sites, hiking up to 12 miles a day with heavy packs.  I found this portion of the course the most physically demanding, but at the end of the day it was unquestionably my favorite section.

 

I’ll write details in future posts, but for now: Pic of the day- desert edition.

 

Day 1- Canyonlands

 

The geology of Canyonlands (actually, the geology of much of Utah) is stunning and fascinating.  This is in the needles are, near Lost Canyon, where we spent our first night in the park.

The geology of Canyonlands (actually, the geology of much of Utah) is stunning and fascinating. This is in the Needles District, near Lost Canyon, where we spent our first night in the park.

 

Day 2- Perspective

 

Looking back at Lost Canyon as we hike out to Elephant Canyon, our next campsite. From many vantage points in the park you could see the snow capped La Sal Mountains.

Looking back at Lost Canyon as we hike out to Elephant Canyon, our next campsite. From many vantage points in the park you could see the snow capped La Sal Mountains in the distance.

 

Day 3- Druid Arch.

 

Before we packed hiked our big packs out to Chesler Park, we took an early morning park out to Druid Arch.

Before we hiked our big packs out to Chesler Park, we took an early morning hike out to Druid Arch.

 

Day 4- The Joint Trail

 

Probably one of the coolest trails I have every hiked, winding through a narrow slot canyon.

One of the coolest trails I have every hiked, The Joint Trail winds through a narrow slot canyon.

 

 

Day 5- Sunrise and out.

 

We left camp at 4am for the 3+ hour hike out.  I led the group of 19 by head lantern for 2 hours before stopping on a bluff to watch the sun rise around 6am.  Pre-dawn hikes are something I will be adding to my repertoire.

We left camp at 4am for the 3+ hour hike out. I led the group of 19 by head lamp for 2 hours before stopping on a bluff to watch the sun rise around 6am. Pre-dawn hikes are something I will be adding to my repertoire.

 

I did not expect to fall in love on this trip, but I have certainly fallen in love with the desert.  I don’t know when I’ll be back, but I hope it is soon…

 

Chesler Park.

 

Chesler Park

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Sandy has come and gone (at least in my part of the country- last I heard she was still making her presence felt somewhere in the middle of the country), but for me (and many fellow New Jerseyans) power has gone and not yet come back.  I weathered the storm in my apartment near school, and stayed there for the following day. When word came that my school would be closed for the entire week (the associated hospitals have remained open throughout), I decided to pack up my freezer and head back to my parents’ place (also without power) where there was storm damage that needed to be handled.

All things considered, my family and I were very fortunate with this storm. We are not on the coast and as such were spared the coastal flooding that has damaged so much of our Jersey Shore. We faired much worse with Irene last year, where flooding led to serious damage at our house and at our farm.  While Irene brought us water, Sandy brought us wind.  The majority of the damage after this storm (at least in our area) is due to downed trees or direct wind.

Of course, with downed trees come downed power wires.  As I write this, we approach 100 hours without power*.  At my apartment, while I lacked power, I had water (and while it lasted, the bit of hot water that remained in the tank). My parents’ old farmhouse is on a well, and as such lacks running water when the power goes out.  Luckily there is a stream that can be accessed for water to flush the toilets and we stockpile water in tanks for occasions such as this. We have lots of firewood stashed (and a good old wood-burning stove), so while the temperatures continue to drop we are able to keep ourselves warm the old fashioned way.  The biggest concern with extended power cuts (for us at least) is the risk of our 2 big freezers defrosting. With hundreds of pounds of beef, lamb, pork, and fish (not to mention veggies and berries), an extended outage gets a bit concerning.  Fortunately we have very generous neighbors who have a generator, and after a couple days without power they bring their generator over so we can plug in and recharge our freezers for a bit (as I write this, we’re on round 2 of recharging- so far so good).

At times such as this there are a number of things for which I’m very grateful .

1-    Health. If you aren’t physically well and physically able this manner of glorified camping could turn into hell.

2-    A gas stove. Seriously. The power may go out, but at least I can still cook. What do people with electric stoves do?

3-    Firewood. And after this storm we’ll be set with firewood for many more years to come

4-    Friends with generators (who not only recharge out freezers, but also offer warm showers… saints!)

5- Merino clothing. Cozy and  stink free… need I say more?

With a limited water supply and a desire to keep dirty dishes to a minimum, I keep my cooking simple. Dinners have been big one-pot numbers (I cooked up a good beef shin bone 2 nights ago and I have lamb shanks on the go at the moment), and breakfasts have been soft-boiled eggs.

“Eggs and soldiers” (soft-boiled eggs served with slivers of toast for dipping) was a regular breakfast when I was a child.  While I haven’t had toast in years, soft-boiled eggs remain a regular part of my diet.  They’re quick, they’re easy, they require no preparation or clean up, and despite this I’m not sure I’ve ever met another American that eats them (my parents are English).  Soft-boiled eggs seem to be quite popular in Europe.  Not only are they part of English culinary history (Go to work on an egg), but I’ve seen them at a number of breakfast buffets while traveling in Germany.

I have no intention of writing a food blog. There are much more capable chefs (with much fancier cameras) who cook and write about delicious and nutritious healthful food (here’s a good example), but I’ll take this opportunity to introduce this tasty treat to my readers (and if I’m completely wrong and Americans are eating soft-boiled eggs like mad, please let me know!).

If you can boil water, you can boil an egg. The difficulty with making soft-boil eggs is getting the timing right.  I’ve sometimes heard soft-boiled eggs referred to as “4-minute” eggs, as 4 minutes is about as long as it takes to cook.  Some variables interfere, such as altitude, size of the egg and freshness of the egg (there’s nothing worse than overcooking a beautiful fresh egg still warm from the chicken!), but 4 minutes is a good estimate.

I’ll admit I almost never time my eggs. I invested in one of these gadgets a few years ago, and can’t recommend them highly enough. If you’re lazy like me and sometimes cook tons of eggs at a time, this little device can tell you when they’ll all be done better than any timer.  Worth every penny (I get no kickbacks, I assure you)!

Once your egg is cooked you can stick it in cold water to stop it from cooking too much or just eat it right away. Soft-boiled eggs are best enjoyed warm and are most easily eaten using an eggcup.  Here’s my favorite:

This was the eggcup my Nan would give me as a child when I visited her in England. I reminisced about it and she kindly gave it to me!

The next step is cracking the egg. This too, is easily done!

Once whacked, you can get to work and open up the egg. If all went according to plan, you’ll have a perfect soft yolk!

Mmmm…. Brains

I like mine with a bit of salt (and sometimes some pepper).

I’d like to thank my hens for eating such a nutritious diet and for having such lovely yolks!

It seems as though Brits are pretty keen on soft-boiled eggs (or at least they have been in the past). Maybe it’s because soft-boiled eggs are delicious, or maybe it’s because eggcups are kind of fun. There are lots of options, from cute little pants sets to fine silver.

An antique silver eggcup set- also from my Nan (I can’t believe anyone ever used these!)

Soft-boiled eggs are not only quick to cook with minimal cleanup (usually just a spoon) but they’re also excellent emergency food.  They’re very nutritious, and they can be cooked in water that wouldn’t otherwise be potable (love that shell!). I remember my good friend Jamie Scott  making that point when he wrote about his experience with the earthquakes of Christchurch.

In college I toured Iceland, including a visit to the geysers. I remember hearing that you could cook a soft-boiled egg in the sulfurous hot springs if you were so inclined (talk about Waste not, want not!), and I tracked down a video of some guys doing just that.  The kitchen method might be easier- no hot spring required!

(As the pictures might suggest, I am going a but stir-crazy, though I have to admit that life without power is not without its charms. I’ve read a big book of EKG interpretation cover-to-cover, dismembered a fallen old maple, fixed a chicken house, and taken the dog for a number of walks over the last few days. I’m also rather enjoying the darkness-imposed early bedtimes (now that it no longer sounds like the wind will rip the roof off from over me!)  More science to come- I do plan to get back to liver and lipids shortly!)

 

*This post is up courtesy of the photons and electrons of a local coffee spot… Thanks Riverside Coffee!

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