Tonight, I am pre-call. That means that starting at 6am tomorrow, I will be up until Noon the following day taking care of patients. Now, in general, I am a pretty pleasant person. However, when you spend your night answering inane phone calls from nurses wanting you to order Tylenol for someone for a headache at 4am and then the nurse realizes she paged the wrong doctor, you learn to quickly become the miserable intern you have every right to be. There has not been one call night this month where I have been able to rest my eyes for more than 15 minutes. My pager continuously goes off because of these ridiculous calls. I don't know if you have ever experienced this, but one of the worst feelings you can experience in life is that of trying to fall asleep and continuously being woken up. Yet, I go through this every 4th night.

When it is just a Tylenol order or Ambien order, I give a huff and just give them an order over the telephone. Things could be worse. The worst things to get called about in the middle of the night:

1. chest pain-automatically requires me to get up, examine the patient, do an EKG (and interpret it) and send off stat blood work.
2. shortness of breath-also requires me to go see the patient, listen to their lungs, order a chest x-ray and then follow up on the chest x ray, possibly give meds
3. patient passed away (patient was comfort care/do not resuscitate)- requires me to do an exam to confirm death, call time of death, call family and inform them, call the attending doctor overnight, call patient relations, fill out death certificate, make sure patient gets moved to morgue
4. arrest stat- you try fumbling back into your shoes, white coat and grab your stethoscope and then make decisions about how to bring back a patient from the brink of death
5. "I want to sign out AMA (against medical advice)"- I had someone do this at 4:00am! Come on people, at least get a good night's sleep before leaving the hospital and taking the risk of you dying into your own hands.

Ok, that's enough cynicism for one night. I just had to vent. Now I can breathe a little easier.

Did you get any sleep? How is your pain? Do you feel any better? What's the color of the phlegm your coughing up? When did you last have a bowel movement? Any blood in your stool, etc...

For the most part, these patients will have a short hospital stay and be sent back to their homes with instructions to follow up with me in clinic or with their regular doctors. They will go back to their daily routines and pick everything up where they left off.

Every now and then, however, I have a patient who's hospital stay will change their entire future. They present to the hospital feeling awful with the hopes that we as doctors can make them feel better. Sometimes, despite how much we want to make them feel better instantly, we can't. There is nothing we can do, there are no tests to run, all we can do is help them feel comfortable.

I have a patient with metastatic cancer. He is dying. He came to the hospital unable to breath, the cancer had spread to his lung and had caused his lung to fill with fluid and he was starving for air. He was drowning. The surgeons were able to help by placing a tube in his chest to drain the fluid. It allowed him some temporary relief. But the fluid that drained was blood. Every time we drain it, his blood counts drop, his lung fills right back up, and we drain it again. His blood counts have now dropped low enough that we keep having to transfuse him with blood. Today, he and his family were told that he only has a few weeks to live. They were given the option of deciding whether they only want us to intervene medically to keep him comfortable, or if he still wants us to do everything possible- i.e. if he stops breathing we will place a breathing tube, if his heart stops we will shock him and inject medication to stimulate every muscle cell in his heart. He was told that if he had a breathing tube placed, it would likely never come out, he would possibly not recover from his heart stopping. He still opted for the latter of the choices.

I'm not sure that I wouldn't make the same decision. How do you face knowing that your time is limited? Knowing that unless we give him medication to keep him comfortable, he will likely again feel like he is drowning. Knowing that every interaction and every experience you are having will all soon disappear. Wonder if your loved ones will miss you being gone and how long it will take for them to get through a day without thinking of you.

I don't know if these are the things that my patient is thinking about. But they are the things that I think about every time I see him. When I see him in the mornings, I make an exception and I don't grill him. I don't ask him "How was your night" because what do I expect him to say... " I stayed up all night thinking about how little time I have left." Instead, I apologize for waking him up, I inform him that I need to listen to his heart and his lungs, and then I ask him if there is anything I can get for him to make him more comfortable.

Honestly, I don't know what else to say to him. I think that no matter how desensitized we get to all the illnesses we see, we are still afraid. We are afraid of being that patient and we are afraid of not treating that patient like we would want to be treated.

I can only hope that of his last few days on earth, I can do what I can to keep him comfortable and try to get through the both of us having to cope with the idea of his death.

Too often, families err on the side of "wanting to do everything" for their family members. I write "err" because I feel that if the family members knew what we knew and saw what we did, they would realize that often "doing everything" is torture to the patient.

The human body can only stand so much of lying around and poking and proding. Patients, unable to move, develop large sores over the dependent areas of their bodies, often down to the bone, which only creates more problems as this is a nidus for infection. Being on ventilators that do the work of breathing, leads to pneumonias and colonization with bacteria. Being intubated (having a tube in your trachea that goes to the lungs to breath for you) can cause complications and lead to narrowing and inflammation of the trachea. Therefore, many people that cannot come off a ventilator eventually end up have a tracheostomy, a hole made into their trachea. Every body function that used to happen naturally now doesn't. You are fed through a tube that goes from your nose to your stomach. However, the longer that is in, the more likely that you can have complications such as erosion into your nasal septum and possible perforation of the esophagus and erosion into the lining of the esophagus. Patients are on constant regimens of laxatives and stool softeners, they have rectal tubes placed to collect their excrement and foley tubes placed through their urethras into their bladders to collect their urine. This is another source for infection. The more antibiotics you are treated with, the more resistance the bacteria build, the more likely you will get worse infections.

I don't have the right to tell anyone that they shouldn't live their life that way. That is strictly my own opinion. But you should be able to tell people whether or not you want to live your life that way. Most states allow you to have a health care representative, a Health Care Proxy. The person needs to be older than 18, and appointed by you to make your medical decisions in a situation when you cannot make any medical decisions. As a health care proxy, the person will be informed of your medical situation and what can be expected in terms of your prognosis. Then, based on your wishes, they can make medical decisions for you. In states that do not use health care proxies, you can have an advanced directive in which you explicitly state what you would or would not want done.

I feel that it is never too early or to late to do this. In fact, I have discussed this with my husband and we are working on our forms. I urge you to be as explicit as possible about what you want done. Consider things such as feeding, drawing blood (which we do a lot), receiving blood transfusions, receiving antibiotics, whether or not you want a breathing tube placed, whether or not you want electrial shocks to be administered in the case your heart stops, or whether you want IV medications to be used. Do your research, choose your proxy wisely. They need to be someone who will act as an advocate for you and who you know will not falter under pressure and decide at the last minute to go against everything you decided you want and instead do what they want. (I have seen this in the case of patient's stating they don't want to live in persistent vegetative states, but their proxies keep asking for everything to be done.)

It's not easy to think about your own mortality, but you have the right to determine some aspects of it. You may not get to choose what cause/illness leads to your life being stopped short, but you get to choose how you want to be treated when that happens.

But, believe it or not, there is something oddly comforting in the routine and monotony of my current existence. I almost don't know what to do with myself on my days off. It's an odd existence when you surround yourself everyday with extrememly ill patients. You forget that for the most part, human beings are generally healthy and most of them are going about their everyday lives and not being poked, prodded, and having iatrogenic complications inflicted upon them leading to prolonged hospital stays. One of the great things about living in NYC is that anytime I feel like there is no one around me who doesn't need my immediate medical attention, I can take a stroll through Central Park and see nannies with kids in tow, dedicated pet-loving New Yorkers with their dogs dressed in Burberry sweaters, the super-funky disco roller-skater getting down to some music only he can hear in his head, and the multitude of spandex clad joggers and bicyclists whizzing by me, working hard to keep themselves healthy and keeping me out of business (which is all right by me!).

While I am incredibly busy and shouldn't even have time to complain, one of the things that I have missed the most since starting work is being creative. I have no creative outlet whatsoever at work. While I do spend most of my days telling patient's stories and explaining what it is that brought them to the hospital, I have no room to editorialize. Stick to the facts, keep it concise, come up with an appropriate plan of treatment and on to the next person.

But, there is so much to talk about! I need an outlet! I need to vent, I can't keep it bottled up anymore. I need to blog.

On the bus ride home one day, we saw a group of workers sitting on a pretty large highway median that had lots of grass on it, surrounded by cows. The cows were just munching on the grass while the workers ate their lunch. A little further down the road were more cows on the grassy sides of the highway. Weīre not sure what they were doing with the cows, but my theory is that they are an inexpensive lawn mower and that is how they keep their miles of highway clean and trim in Quito.

Work has been very interesting. I have become very familiar with sewing up machete injuries as that is the major mode of assault here. One patient had the tops of three fingers chopped off, a cut on his neck, and some tendons torn on his left hand. The last machete patient had an exposed ulnar fracture and his ulnar nerve cut. Ouch is right!
I think that preventative medicine is a huge problem here. One morning during triage we diagnosed 2 women with some kind of uterine cancer and another with gastric cancer. They wait too long to come in and when they do itīs too late. Itīs very sad.

We had the weekend off and a group of us decided to go sight-seeing to a town called Baņos were there are many hot springs. We got there on Friday night and stayed at this gorgeous hotel up on top of a mountain in a log cabin. (All for less than $25.) But, we were in for a little surprise. I was sitting in a chair enjoying a bottle of pure water when out of the corner of my eye I saw something large and brown. Oh my god, it was a scorpion! Mind you, it was only about 6-7 cm long, but arenīt these things deadly? I start yelling and get all the other girls over to come inspect it and none of us wanted to kill it. There were 7 of us hovering in a corner opposite of where the scorpion was trying to figure out what we were going to do. Some of us took pictures of it thinking the flash may stun it and others wanted to deet it to death. Another suggested throwing a shoe at it to see if it was even still alive. Finally, three very brave girls ventured over with a tennis shoe. The first hit only made it run, but with the following three hits we said goodbye to the scorpion. We then inspected every nook and cranny and under the covers and in every shoe before we were able to go to sleep. It was a very eventful night.

To make up for it, we spent the next day lounging by the pool of our hotel. Then we walked around the city to take in carnaval and the sights. We also took a tour to see the volcano Tungurahua, which is an active volcano. Baņos was evacuated as recently as 1999 when the volcano went up to orange alert. By 2000 most inhabitants moved back since it had not erupted and everyone was desperate to get back home. The volcano is currently on yellow alert (scale: white-yellow-orange-red; orange=90% chance of major eruption over coming weeks or months). So, we all piled into a bus and took a death defying bus ride up a mountain to check out the volcano which can be seen spewing out some ash and the like at the very top. However, it was pretty cloudy and rainy and we ending up mostly listening to the rumbling of the volcano.

On Sunday, we got on the bus and went to Ambato to see the great parade of fruits and flowers that takes place for carnaval. There were so many people there and it was so crowded that we only stayed for a short time. All the floats were intricate and it was amazing the designs that they made from the flowers and fruits. Afterward, we headed back to Quito for a relaxing night before going back to work.

Another interesting note, I was able to last 3 weeks before getting the Big D. Thank goodness for Pepto-Bismol!

Iīm not totally sure how to describe the experience... intense...sad...devastating
...overwhelming. We got split up based on what we are going into. I guess the donīt have room on the general medicine teams because they wanted me to stay in the ED. Within the half hour we were there, we started with a tour. I saw probably easily 70-80 people waiting to be seen. There was one person on a stretcher in the hallway covered in blood and yelling in pain. Another person had a hole in his chest that was being stitched up in the hallway. One person arrived via ambulance and had what looked like a gunshot wound in his abdomen (a gaping hole) also yelling in pain. He got taken to a trauma bay, had an IV placed and then was transported to another hospital. I also worked with an ob-gyn and saw two patients. One who doenīt know her due date and they had no info on and she was coming in for follow-up. Another, who possibly had pyelonephritis and was having contractions at 32 weeks. She was going to get admitted. What struck me the most was the tremendous lack of resources.

Today I worked ER triage. It was abdominal pain day. Everyone had diarrhea, fevers, vomiting. It was hectic. The resident I was working with didnīt even have gloves to use when starting IVs. The EKG machine consists of metal discs that you have to attach via suction. Itīs hard to explain, but there is a bulb on the end of the metal disc and you squeeze the air out and then place the metal disc on the skin to get it to stick via suction. I had obviously never seen one of these before and it was an interesting experience trying to figure out how to get it on. The good thing about today is that I learned that my Spanish is much better than I thought. I was able to do histories and physicals on everyone without difficulty. I still have to learn how to write everything out though, and learn their abbreviations here which are very different. The medicines also all have different names here. I have to go back and learn all the generic names. I think that it will be a great experience and will give me a new found appreciation for the health systems in the US. But, I wonīt know for sure until I have completed the experience.

On Wednesday morning, I woke up in a bit of pain from my sunburn. Most of the day I spent doing research on my presentation (Health Systems in Ecuador). Wednesday night, though, I think was the highlight of our stay here so far. We traveled by bus to a small town named Iluman, where we went to see a cleansing ceremony by a Yachac. Atscko, a fellow student, volunteered to be cleansed. She had to dress in a sports bra and some shorts. The ceremony began with the Yachac praying in Quechua. He had Atscko rub some scented oils over her body and some water with herbs. He also spat some alchoholic fluid on her that she had to rub into her skin. He used some plants, one called Ortiga, with really small leaves, and used them to "beat" her. He also cleansed her with some eggs and placed an incense fire under her. The yachac also spat fire at her by drinking some alcohol and spitting it over some candles. It actually singed her hair and burned the hair off her arms! In conclusion, she received a necklace. These necklaces used to be used in marriage ceremonies and were a symbol of the union between husband and wife. In Atsckoīs case, it is a symbol of her "marriage" with positive energies. The plants and eggs that were used to cleanse her body of negative energies get buried somewhere sacred, like near a river, to make sure that no one else finds them and then absorbs her negative energies. I took lots of pictures of the whole ceremony, so someday you can see what I am talking about.

On Thursday, we visited a small village called Mojanda and went to their local community clinic. We met with one of the directors who gave us some history about the clinic. I couldnīt believe that this place services about 1200 people (600-700 families) on an annual budget of only $7000 and in only a six room building! Each family in the community is asked to donate $1-2 dollars for services. The remainder of the budget they get from donations from the US. They do everything from pediatrics to ob/gyn. Some years they also get an MD from the states to come for a year and help out. It definately seemed like a worthwhile cause.

After the clinic we visited Casa Mojanda, which is a resort on the side of one of the many mountains surrounding Otavalo. The resort is run by an Ecuadorian-English couple. They also started and help to run the Mojanda clinic. Itīs a great place to escape for some peace and quiet and to just be surrounded by nature. Just wait til you see my pictures!

Friday morning we headed back into Quito. Luckily, we didnīt encounter any road blocks this time. We arrived at our new hotel and unfortunately, they screwed up our reservations. We were supposed to have suites that had kitchens in them, however, they already had those rooms occupied. So, we each got doubles to stay in and we have full access to the kitchen in the hotel so we can cook some food for ourselves. Overall, I think the accomodations have been pretty nice. You just have to get used to some of the local customs, like not flushing toilet paper-you have to put it in a waste basket. We also have to be pretty careful about brushing our teeth with purified water and not tap. You have to be really careful, especially when you go out to eat and remember not to eat salads or anything uncooked and not to get drinks with ice. The first thing Iīm going to do when I get home is have a huge glass of water filled with ice! Iīm also going to eat lots of apples and grapes and veggies! (Canīt eat anything you canīt peel!)

Saturday morning we got up early to go on a tour of the National Park of Cotopaxi. Cotopaxi is Ecuadorīs second tallest volcano and one of only seven active volcanoes in Ecuador. Ecuador actually has about 400 volcanoes in total. Cotopaxi is also the tallest active volcanoe in the world. We had a tour organized with a couple geologist who gave us lots of information regarding the park. They also do research on the volcano and told us that they have various methods (seismographs etc..) to get information about the volcanoīs activity. Apparently the volcano hasnīt erupted since the early 1900s but thay have been getting data from the inner core and it has been quite active. They believe that the volcano will erupt again within the next 10 years and they are working on methods of evacuation because even though itīs about a 3 hour car drive from Quito, the lava from the eruption would flow down to Quito in less than an hour! When you get to the park, you can actually drive up 2000 meters to get to the hiking area. From there, we hiked 300 meters to the very bottom of the glacier. The top of Cotopaxi is actually a glacier and is covered with ice. Every year, it has been receding due to global warming. At the very bottom of the glacier, we were at an altitude of between 15,000 and 16,000 feet. There were amazing views everywhere you looked. On our climb up, we could see the remains of what once was a huge lake. The lake is actually 1 million years old, but it has been drying up due to changes in temperature. We asked if there have ever been excavations to look for fossils, etc, but since it is a national park, there canīt be any work done in the area. On our way to the glacier, we had to climb over and through tons and tons of rocks. These rocks have all been there since the last eruption and are essentially pieces of the top of the mountain that were blown off with the eruption. It was a great way to spend the day and of course, I took a ton of pictures to show you all!

Today, Sunday, I took the day off and just wander around Old Quito with 3 of my companeras. We climbed up the top of the basilica of Quito where you have views of both old and new Quito. I again took some great pictures.

Tomorrow, I am starting to work in the hospital. I will be working in the Hospital del Sur on the southside of the city with 3 other students from my group. I will fill you in on the experience later this week.

I have been informed that my entries donīt read very well. I just thought that I should explain that I am usually very rushed to make my entries and I donīt get very much time to think about them. I am just trying to get the main points across. Forgive me for not being eloquent.

I will update on the rest of my week which includes stories of fire and ice!

Rachel, in answer to your questions, I donīt know that I am necessarily learning something that I can apply in my treatment of patients. But I am learning what the traditions and cultures are and how the people here take it very seriously. So, I need to learn how to be able to respect their beliefs and also teach them about how Western medicine can complement their traditional medicine.

After the clinic, we went to San Luis Hospital de Otavalo and had a tour. The conditions are pretty poor and currently the doctors are on strike for higher wages. They strike from 8 to Noon on Monday and keep adding an hour every day to the strike. This is pretty common. The resources are scarce and they even recycle their gloves. We saw them hanging everywhere. I donīt quite know how they are sterilized without being melted, but then they hang them to dry. They have cots for beds and the paint is peeling off the walls. The other terrible thing is that with the strike, patients can be waiting all day to be seen and not even get seen and be sent home to come back the next day. Medical care here is on a first come first serve basis, so if there is not enough time for you to be seen your stuck waiting until the next day. The experience made me realize how fortunate we are in the US and also that I would really like to do more to help, I just donīt yet know how.

On Tuesday, we had the day off. We organized a tour to go on a 2 hour hike up a mountain where on a lear day you can see 3 lakes and 10 volcanoes. I didnīt think it would be too tough to do. So, our tour guides drove us to Lagunas de Mojanda. But, then we climbed about 1500 feet to the very top of the mountain and most of the climb was at least at a 45 degree angle! It was tough. For some parts I pretty much crawled and had to use my hands to pull myself up. On our way up we saw a herd of wild bulls and from the top we were able to see 2 of the lakes pretty well, but then the clouds rolled in. It was still amazing to sit at the top of the mountain eating lunch and being surrounded by clouds. Our hike down also included some rock climbing. On our way down the sky cleared up and we had gorgeous views of beautiful rolling green valleys. We also saw a few eagles flying around us. I definately felt like it was a great accomplishment to climb this mountain and see so much wonderful nature!

Today, Wednesday, we are all working on different research projects about Ecuador. My groups project is to talk about the health systems in Ecuador. Tonight we have more spanish classes and conferences and after that we are going to visit a Yachac to see an actual cleansing ceremony. Two people in our group have to volunteer to have a ceremony performed on them. It should be pretty interesting. Iīll try to take some pictures of that too!

On Sunday, our directors had arranged a whole day of touring. We started off in a small village where we learned how to do some special weaving of mats. From there, we visited Laguna de San Pablo at the base of the mountain Imbabura, which is a huge lake about 4 km wide, where every year there is a race to see who can swim across it the fastest. The prize is $1000 which is A LOT of money here. The natives start preparing 2 weeks prior to the race and they spread snake fat on their bodies to help them retain their body heat. From there, we went to another small village named Carabuela and met one of the few traditional weavers. He taught us how to work the wool and how he spins it on a loom that has been in his family for 120 years. I bought some beautiful tapestries and scarves. We then visited the house of the Ecuadorian woman who helped make the documentary about Otavalo. One thing I have to say about the Ecuadorian people is that they are all so wonderfully nice and accepting! They take you in like you are family. She showed us her little organic farm and gave us some fruits to try. We tried some granadillos which are like pomengranates only orange and some guavamachete a big green fruit shaped like a machete that has a furry white flesh with big black seeds. I did not like that one too much, but the granadillos were yummy and it was fun to try. After having lunch in Otavalo, we finished our day in Cotacachi a town where they specialize in leather work. There are tons of little towns up and down the street that all sell a bunch of leather products. Then we finished at the best site of all. The laguna de Quicocha which is a huge lake that formed in an eroded volcano. I have never seen anything so breath taking- I took a ton of pictures.

So far today, we went and visited a clinic in Otavalo where they practice traditional medicine with shamans and then to the San Luis Hospital of Otavalo. I will write more about that tomorrow.

I miss you all, but I do not miss the weather!

At dinner we had an Andes band play music for us. David, I know you would have hated it. Lots of songs with those pan-flutes you canīt stand. But, there were cute Otavaleņa girls that came and sang and danced. I took lots of pictures to share with you all soon.

So today my third day here we did some exploring. We had an assignment to go to the Peace Corp and learn about what they do in Ecuador. While walking to the bus stop, I was standing on a corner with 2 other girls in my group. I see this bus approaching with this little kid in a school uniform hanging out of the open door (prettycommon here...people also just jump off the bus to get off). What I didnīt notice was the giant super soaker in his hand....until my friends and I were completely soaked that is! Needless to say, my Spanish came in handy as I yelled some not so nice things at him. We made it to the Peace Corp without any more events despite the trauma of trying to find the right bus to get on and jumping off of it. We decided on the way back to take the trolley instead.

Tomorrow we are off to Otavalo. They have a great indian market there on Saturdays and we will be touring around the mountains. Hopefully, super soakers arenīt sold around there.