Scream I

Have you seen it? Where the Wild Things Are? Growing up, Spike Jonze was my favorite music video director. As a grown up, Dave Eggers is my favorite author that I've never read. The two creative masters somehow met, obviously in some creative way, and co-wrote the screenplay to the movie, Where the Wild Things Are.

One of the opening scenes, perhaps the very, portrays, Max, the pajama bearing protagonist exercising his own creative genius to ambush his teenage sister, Claire, & her friends with snowballs as they leave the house. His plan works perfectly, the kids exit the front door and Max's brilliantly choreographed attack ensues. Once his ammunition is out, Max triumphantly retreats to his igloo fort grinning ear to ear. All of a sudden, his mood is suddenly and literally crushed as one of Claire's friends pounces on the fort decimating it, burying Max and his bliss. The teenagers split, oblivious to the mess they've created and Max erupts with tears, snot and saliva. In this constellation, the flushed cheeks, runny nose, and agitated breathing, this is the first moment in the film where the audience is reminded of what it felt like to be nine. The rest of the movie, scene by scene, reminds the audience of that feeling in equally direct or more roundabout ways—not ignoring the bliss, but focusing on the frustration. From Max's tantrums at home to the howling on the island's cliffs, Where the Wild Things Are is one collective scream; a shout against the ineptitude of childhood; a cry against a world that is incomprehensible; a plea for attention; a yell for someone to come and institute some order and understanding on the island of prepubescence.

This collective scream reminds me of another epic yell. Did you see the movie, Garden State? Perhaps you heard of it. I actually didn't know who Zach Braff was before this movie—no Scrubs at that point in my life. I did, however, know all of the great bands featured in the movie's soundtrack. Basically, write a script about a pretty typical American twenty-something's life. Add an unusual element to the story for hipness—like a friend who has a mansion because he successfully marketed silent velcro—and then play a bunch of awesome songs in the background and you've got a solid movie, Garden State.

One of the closing scenes portrays the main characters of the film donning trash bag rain coats standing on top of an abandoned bus that sits at the bottom of a landfill—I think, can't actually remember if it is a natural gorge or landfill converted junk yard. At this point in the film, the crew has spent the entire day running errands, to what is an unclear end. Regardless of whether they are winners or losers, what is obvious is that they are at the end of their scavenger hunt. Rain is coming down, and it is time to call it quits. Just as the audience settles into emotional coma, Zach and his two friends climb unto this bus and scream, first Zach, and then all three in unison. They scream with everything, they scream with every respiratory muscle from feet to lips. This is it; this is the moment where the film transcends from musical candy to art. This is where the predominantly twenty-something audience wakes up and feels a personal connection, because this is the scream of our generation, the howl of generations past. It is the yell against a world of insurmountable problems--poverty, global warming, war, social security, health care; it is the scream of the heart ache of understanding; it is the yell for being empowered and accomplishing what feels like nothing; it is the scream of emotional incompetency still unshaken from childhood; it is the cry for dead loved ones; it is the yelp for dead love; it is the cry for control in an uncontrollable world. It is the cry for someone to fill the hole in the ozone of adulthood. It is the scream that we all let out when we realize that after all we've done and may hope to do, we are in a giant junk yard, wearing trash bags, and standing on a bus that doesn't work.

Dr. Jerry

I'm afraid that I'm falling in love, and I can't fight this feeling anymore. This letter is a small token of the significance of this new relationship. I blotted out the name of the sender per our discussion in "advisory dean lunch" about posting patient information on the Internet. Three cheers for HIPAA.

I saw, EB (this is how the medical/science world refers to a patient in public), last week in my preceptor's office. The first thing that caught my attention on her chart was the fact that she was 93. Yes, 93! The laundry list that followed--pneumonia; breast cancer; lower back surgery; vertigo; diabetes--actually seemed short for someone who has lived through two world wars, two influenza pandemics, two atomic bombs, two towers crashing, two presidents Bush, two panda bears born at the DC zoo. It is like she's lived twice, already.

Anyway, I looked up why she was in today, reviewed some lab values in her chart and entered the exam room. I was expecting someone much...older looking, er, someone with less pep. I expected a walker or cane, or a crumpled husband to be at the patient's side. Instead, there was this feisty old woman sitting upright in the chair giving me the sternest yet friendliest of looks. I shook her hand and took a seat as I introduced myself. I then put her bible sized chart on the counter to my side so I could focus on her and not the 93 yrs of health records straining my arm.

I can't remember the details of the visit as to the specific order of things we covered, but somehow it wasn't long into the visit and we were talking about her restaurant that she owned, that was so, so long ago to her. Even longer back was the divorce of a loveless marriage. Her mother died when she was only 16 (also felt SO long ago for her), leaving a handful of siblings for EB to raise. EB didn't think she would ever marry, at least she would completely take it off the table after the age of 25. Well, luck would have it that at 24 she started dating a young man who eventually proposed to her. She remembers that day at the altar, remembering that she did not love this man, and somehow, the Father understood this, but counseled that this was the right thing to do.

Hello! Can you believe that? This visit started to feel less like I was interviewing a patient and more like I was reading a James Joyce story (The Dead, specifically)! My brain continued with the interview but my mind caught up trying to process the significance of that statement in the patient's life. To live seventy years knowing that you were once married, and divorced of a man you never loved. She went on to tell me more about that situation and others that I would like to write about; but I feel mentioning those things would somehow invade her privacy, even with applying the cloak of anonymity, er, I just want to keep that between us. After the divorce, and back on her own, she dedicated most of her life to raising or caring for extended family, nieces and nephews. A life of total service.

She can't fly on airplanes because of her vertigo. She tires easily, and her hearing is going. She was very supportive of my desire to live to 100, but she had no interest in living another seven years. Despite her indifference over being a centenarian, she seemed so vibrant to me. I don't know, I think she can make it.

There wasn't anything interesting, medically, about this visit. Later that day, and yesterday, I saw some very interesting cases. Cases where I actually knew what I was doing, knew what I was finding on exam. That was really cool. But EB's visit was different. It was one person putting enormous trust into an encounter, the other, putting a lot of honest effort, and hope, and a little bit of expertise; It was two strangers meeting and leaving as friends.

EB stopped in the office the following week to give me this letter. In it was a medallion of the Virgin Mary. It is called the, Miraculous Medal. I am going to keep it in my white coat for as long as I practice, or as long as I wear a white coat, as a reminder of the miracles.

So I'm falling in love with patient care, with internal medicine. I can't help it. And actually, that scares me. I honestly was hoping I'd fall in love with something that pays my loans off. But that is another post...

Before and Happily Ever After II

It has been so long. And the entry I really wanted to write tonight will have to wait another day. Instead, I hope you find this house update satisfactory.

I closed on the house the day I came back to Rochester, following the escapade in South America. There were nine days remaining before class resumed. I thought about spending that time fishing--something I wouldn't have time for once school kicked up again. But then I thought about how the house was empty, and soon it would be full--well, more full than totally empty; you can't rush furnishings. So I decided to go handyman and refinish the upstairs floors.

Four days of non-stop work from 7:30am to 12:30am and the pictures can show you what we accomplished. Mad props to my momz and Greg and Kamesh and Mac and Miguel for their help on the project. It was slightly less brutal and only possible with their help.

Sorry that the pictures don't match before/after. I wasn't planning on doing any before/after pics. I will try to do that for any future projects. And please overlook the formatting mess. That is another project I am in the middle of, remodeling the white space of el blog. This blog is under construction. Enjoy, but scroll with caution!

Before / After

A Problem of Pediatric Proportion

I finished my Peds rotation! OK, well, sort of. I'll have to go back to this clinic in January for another five week stint, but for now, I'm finito. At least, I finished enough to call for celebration.

I'm so over children :) Is it the kids that I'm over, or the moms? Before we begin seeing patients in the afternoon, all the residents and I get together with the attending to review some topic of care. Today we were going over asthma but the conversation got a little off track and one of the residents wanted to discuss when the child should be taken away from the mother's care. You know, due to "dumb mother syndrome." See, this is the advantage of being out in the clinics. You don't learn about dumb mother syndrome, DMS, in the classroom.

The manifestation of the disorder is clear. A post pubescent female presents to the pediactric clinic with a small child assumed to be their offspring.

OK, there is more; not every mother who brings their kid in is considered "slow."

The post pubescent female mentioned above, in addition to bringing her child to the pediatrician's, will demonstrate one or more of the following:

Continues to smoke around her baby already diagnosed w asthma
Does not allow her child to be vaccinated
Fails to fill her baby's prescription


Uh, am I missing any? Please be on the lookout for these signs. The CDC has noticed a spike in DMS within the past nine months and we want to put a stop to it before we have two pandemics on our hands. Do your part and report DMS, ASAP, to your PCP, the FBI, CIA, or any other acronymous (just go with it) organization!

Before & Happily Ever After

A few weeks ago, a patient answered my first question with, "Well, I bought three cars last week." I wasn't expecting to hear anything like that. I did not ask how many cars he or she bought. I did not ask anything related to purchasing behaviors. I just asked why he was here today. It didn't take many more questions before it was clear that he was seeking treatment and help with his bipolar disorder.

I've been suspicious of my own self and my bipolar tendencies ever since my grandfather was diagnosed with this illness. Well, it wasn't three cars, but I did buy a house this summer--slightly manic, yes. My recent conversation with this patient made it clear, however, that I am in no way bipolar.

No, it wasn't mania that led me to purchase a house. I just wanted to take care of something, to be responsible for something--and I was done with landlords, and I thought I could get a good ROI. Most everyone feels this way (responsibility/care) at one point or another in their life; and the traditional response to such a desire is to get a pet. Right? And how likely am I to do the traditional? Hence, the house.

Medical school is not the best occupation for someone interested in hobbies and such :) but here is a start at documenting some of the care I get to provide, outside of the clinics:

A couple of the doors in the house wouldn't shut. And I noticed they had the original door hinges from 1880. The doors needed some adjusting and the hinges just needed some cleaning (many hours of boiling and wire brushing/beeswaxing).

And after taking 140 yrs of paint and gunk off:
PS does anyone have any suggestions on bathroom tiles? Quick, I'm gonna do that soon!

Aphasia

We're going 21st Century:

I'm pulling out all the stops this year. First, it was pipe cleaners; Now, YouTube. Sometimes, my jokes become a reality...

I was assigned to teach my group about the various aphasias a patient might present with following a stroke. Aphasias are disorders related to language. Some aphasias inhibit one's ability to speak, others inhibit one's ability to understand speech, etc... Aphasias come in all flavors and are absolutely fascinating to observe and ponder the electrical processes going awry in the brain to produce the apparent disorder.

Enjoy!

http://www.youtube.com/watch?v=bBYW7MSKHWg

Picking Apples

As of this morning, first test of the year, check. Now, how many to go?

I had my fill of being measured (the exam) this morning so I turned the magnifying glass around and spent the evening doing the measuring. I measured heights, weights, muscle tone, bulk, strength, blood pressure, and so on. Today, I went out with a rural med doctor to do visits to the migrant workers in upstate, NY. They come every fall, the fruit pickers from Mexico, to the finger lake region to pick the bounteous harvest of apples, peaches, and such that blanket the area.

Did you check out that link? Because, really, that might be the point of this post...

And the other point...to report that it is awesome to be back in the patient setting. We were doing school physicals for children who just moved up to the region for the picking season. I love riding around the trailer park neighborhoods like I'm some kind of an ice cream/medical truck dude. The kids were actually really excited about their physicals. These exams were less examination and more celebration. One kid, RH, couldn't stop laughing during the hernia check. Whatever; I'm having fun if they are. The kids loved it so much, we hugged me as I and the doc split!

I left the house feeling some kind of a euphoria. It is a feeling that is hard to describe. Cautious joy?

The visit is great, you find that the kid is mostly healthy, you talk about the sports they are going to do in school, all the fun that awaits them, you tell them how great they are, because it's true, you can feel it; but what does the future really hold for the kids? What is the life of a migratory worker? The dinner table is decorated with a big jug of Sunny D and a 12oz can of Coca-Cola at each place mat (we interrupted their dinner). I leave wondering did I counsel them enough about brushing their teeth? Will they really reduce the soda in the diet? Why did I talk about this with the seven year old and not the mom? UGH! So I'm just learning, but is it right for me to chalk up someone else's health care to my learning? It is likely that another year passes before the kids or the parents are seen by a health care provider. Another year may pass without understanding the role their diet plays in their future health. Is it just another year closer to diabetes, or did the visit mean anything more than a formality required by the county/state/fed board of Ed. Only time will tell?

And We're Back

I wasn't prepared for this summer. I wasn't prepared for how fast it was going to pass, I wasn't prepared for how fun it was going to be, and I especially wasn't prepared for how depressing it was going to feel to return to my career, my life as a student. The drive up to Rochester is always beautiful but this time it was particularly gorgeous. I must have still been experiencing some kind of a traveler's high because the following day I experienced serious withdrawal. Tremors, panting, sweating, flushed face, etc. The realization that I was a student, not a researcher, not a traveler, not an explorer; yes, an abused, debt-riddled student was a little to much for my mind to handle.

And then it happened. I walked into class(we started back on the 10th), fifteen minutes late of course, just in time to catch the closing remarks of the Dean. Five hours later, I was feeling pretty good. And the next day, I felt even better. And the third day, I even got out a pen to take some notes. The notes came so easily and everything about my schedule seemed so routine that I figured being a student was a lot like riding a bike. Now that I think about it, there are more similarities than its ease to pick up again. Both activities make it very difficult to keep let alone gain any weight... Uh, well those are all the similarities. I'd say they were both detrimental to the crotch but the soreness is more generalized from studentry than with cycling. Oh, another similarity, they both are extremely tiring.

Not only the lectures (very tiring to listen to people talk; I thought I was a good listener but it turns out, no, not a core strength for me) but the assignments of a student are draining and are usually carried out in the wee hours of the morning. After merely three days of class, there I was on my living room floor working on a way to teach my colleagues about the circulation of the brain. Pictured below is my answer. I went to the craft store. Yes, that is true. I went to the craft store and bought enough pipe cleaners for me to practice building a couple of models and to cut up pieces for everyone in my group to build an arterial blood circulation model the following morning in our PBL group. It was a huge hit. One student who was not in our PBL asked me later in the day if he could buy my model. I laughed at the idea and offered him another for free, but hey, there is a business plan circulating here!

Oh yeah, appreciate how the anterior cerebral arteries arch back to give branches to the cingulum and frontal lobes. Que Belleza!

uh, yep, this is really what we medical students do after everyone else has gone to bed

It Takes Two, Baby

My absence on the blog suggests that I was kidnapped by the Shining Path, but fear not I am well (er, that is a tricky statement recognizing that I am back in medical school, back in my cage). It took surprisingly little to adjust from the Inca paths I grew so fond of this summer back to the medical-doctor-business trail. Before I move on to all of the "adventures" of medical school, I want to at least a mention of the adventures experienced in the later half of the summer.

We crossed paths with maybe a handful of people over our six days of climbing and descending mountains in the Vilcabamba range. The barren trails opened mountainside after mountainside to us; each one stood unique in its beauty, yet telling a similar story. They all seemed to say, "go back to where you came from, the land is too high, the rock too deep, the soil too dry, the air too thin, man does not belong here."

The Vilcabamba has always been a region of dry air and impossibly high peaks, fast flowing water, and dry, dry earth. There are very few people eking out a living among the condors and vegetation that now inhabits the Vilcabamba mountain range but this was not the case during the reign of the Inca civilization. They built extensive roads to connect their people and their resources. They built even more extensive waterways to irrigate their brilliant terraces (in Quechua, these are called andinos, hence the Andes). They built entire cities, green, sustainable cities atop mountains. In the day of the Inca, these mountains teemed with life, with running water, with crops year round and storehouses a plenty. The Spanish were never able to cultivate the land like the Inca, so the mountains returned to their uninhabitable state. It is a disgrace that the real caretakers of the land, the Inca, had to give it up to such an incapable, ignorant people.

What was it that enabled the Inca to thrive? Their civilization grew and developed so rapidly because of the unity of the society. Not to say that they were united in freedom--that concept was totally foreign to them--but everyone contributed in some way, whether it be to build the road system, farm terraces, weave clothing, everyone contributed and everyone ate well. Those currently living in this region now struggle on their own to feed their crops and their livestock. Their children are burdened with malnutrition, and despite their isolation, they are dependent on goods from towns that are days away by mule. Take home message: teamwork can lead to great things. The Inca civilization accomplished SO much and it was because they all worked together--we'll ignore the details of how people decided to contribute for now. Seriously though, as I hiked the remains of the Inca trails in the Vilcabamba mountain range for six days, climbing and descending, and climbing, I continually thought how miraculous it was that these people were able to thrive in such a challenging environment. Where it is hard for one man to breath, they were able to build and support an entire community.

So the Beatles had it right, as they always did: "Come together, right now..."

Now a few pictures to show the current state of the Vilcabamba.
HUGE DISCLAIMER: Blogger is pathetically diminishing the size and quality of the photos. Viewers, beware!

The town of Cachora is exploding with development due to the increased tourism to Choquequirao. Choquequirao is the sister city of Machu Picchu. Much larger, much more spread out, much further from civilization, much harder to reach (can only get there by foot), and much less of it has been excavated. The later reasons are why few go to check this place out. Lucky for us. Cachora is where you start the trek to Choquequirao. Got it? The picture was taken at the entrance to the house where we loaded up our mules and headed out on the six day journey.

OK, so exploding may have been a little strong to describe Cachora's development...

The end of Cachora, the beginning of the trek.

Behold, the barrenness

Yes, that is the barren trail you see

Barrenness, day two

Plenty of vegetation, but no civilization.

Where life once thrived, Choquequirao

this is what greeted us on day four upon reaching Victoria Pass; after climbing all afternoon the day before and the entire morning; from the river bed of the valley, up ancient Inca stairs, above seemingly all living things.

We decided it was a nice spot to appreciate the barrenness over lunch.

In the interest of time, and storage space, I'll finish the rest of that trek with a quick summary. We spent the rest of day four, and the majority of day five hiking at the feet of glaciers. Day six was a gradual decent to the ceja de selba, or the "eyebrow of the jungle" in English. We reached Aguas Caliente by night and day seven was spent on Machu Picchu--I actually opted out of MP since I was there two years ago but hiked up a neighboring mountain, Cusiputu, instead.

The view of Machu Picchu from atop Cusiputu

These stairs continued for about 100m. I took the picture on my way down.

Update: Because I Have a Second Tonight

It´s been a little difficult to get to the cybercafe lately. I apologize for the delay, but here is an attempt to keep you updated. Thanks for checking in :)

Making my way along the old caminos of the Inca

The bath house, because the inhabitants of Choquequirao had to bathe themselves somewhere.

Strike Two

We left Aguas this morning on the 530am train to Ollantaytambo as planned amd that is where our plan started to fall apart. Wouldn´t you know it, a strike was planned for today to close all of the roads to and out of Cusco. Luckily, it was still early in the day and there was one country road that a taxi driver believed would still be open. We worked out a deal for him to take the three of us and three other American girls we met on a previous train (we kept running into them over the past two days) to the promised land, Cusco. We tore out of that small town, Ollantaytambo, like a saint out of hell--really, what does a bat have against damnation? I felt bad for the droves of people stranded in Ollantaytambo´s main plaza as we passed by but there wasn´t really anything we could do aside from be grateful for our transport. We still were not sure if the road would be open the whole way. There was one point we came to a log laid across the road. The driver jumped out to quickly move it but it was too big for one man. Zach and I immediately followed out of the van to move the log. We later debated the possibility of having significantly harmed our back or neck in the process but we got the log off the road and our van was on the move again. From then on we made it to Cusco without problems!

Instead of taking a bus out of Cusco at 11am for Lima, our voyage is delayed until this evening, giving us enough time for the blockade to be taken down (for the farmers to go home and let buses through) by the time we reach the perimeter of the strike.

This means I have an extra afternoon in Cusco. Let´s try to upload some photos!

We hired a boy to carry our packs for a half a mile or so. We hired four or five bikes throughout the hike, none able to help for more than half a mile, unfortunately. Some bikes were even threatened or attacked by the strikers at the road blocks. The indigenas on strike did not want anyone helping us on our way. They let the air out of one poor boy´s tires. That made me mad to the point that I pushed one of the farmers away from the kid´s bike. Then this old farmer got in my face (more like my chest cause of height issues) and we grabbed our packs and split without looking back.

One of the blockades had trucks backed up for about half a mile. Locals had painted the sides of the buses and trucks with their propaganda.

The afternoon on Choquequirao. Chillin on the terraces.

One of the glaciers we walked by on our trek. The highest pass that we crossed was about 14-15,000ft above sea level.

Uploading is taking WAY to long. Esto es todo por ahora. chao!

30 hrs in Aguas Calientes

OH my! We made it to Aguas Calientes (the small village at the base of Machu Picchu) last night. I would love to post pics of our trek over the past week but the internet connection is not wide enough here, ya know, band width ´n such. Seriously, I just waited twenty minutes to upload ONE picture--not happening. Hopefully there will be time to post some pics tomorrow before we leave for Lima (We are taking the train out of Aguas in about five hrs, I´ll have to write about Machu Picchu another time).

The gist of the past week: We left Cusco at 6am, four hr drive to a small village called, Cachora. There, we met up with Alfredo, the useless guide, Chino, the chef, Florantino, the leader of the pack (the pack being two guys that un/packed the mules and tended to other duties, and our new friend, Keeko, he is the guy who we met in Sicuani. After about an hour of eating and organizing the gear, we took off on the trail to Choquequirao. Two days later, we arrived at the largest mountaintop city of the great Inca Empire. An immediate sense of reverence was felt upon entering the high andean city. No tourists, no guides, no nothing; only an occasional flock of bright green birds shreiked through the sky disrupting the quiet that lay over the city. It felt like a ghost town. It felt like the city´s inhabitants split in serious haste leaving nothing but a curse on those who followed. It was a bit eerie, if I haven´t gotten that across yet. Most of the trails were unmarked and had to be explored, the exploring we did as kids in uncharted forest (remember, Jayden and others). Instead of uncovering salamanders and fishing holes, we came upon homes, garden terraces, and bathing pools. We spent the remains of the afternoon exploring what we could and then retired to our campsite on Choquequirao´s hillside. We took up more exploring at sunrise and moved on from the ruins at about 12 noon.

What followed was what felt like an eternal decent. A literal falling from grace as we dropped down the backside of the lofty city. We took the trail down, down, down for two hrs, broke for lunch (my knees, my body couldn´t take anymore), and then climbed, climbed, climbed for about three hrs. Completely exhausted, we camped on a small farmer´s plot at the top of Choquequirao´s neighboring mountain, Maisal. We got there just in time to watch the sun drop behind the high shelf of snowcaps lining the western horizon. In a matter of minutes, the sky went from gray to rose to black, followed by a tremendous display of stars in every direction.

I think it was Ronan who explained that the Incans made constellations out of the dark patches in the sky, rather than the stars themselves. That makes total sense when looking at the sky from a Peruvian mountaintop. The milkyway and the stars are so bright that it is easier to pick out shapes of black--and there are far less black splotches than stars to keep track of. We star gazed and chatted with the polish couple also trekking through the Incan wilderness until we were too cold and in need of warming up with mate and soup complements of Chino & company.

The following day we continued our climb on Incan trails, passing old incan mines, climbing stone stairs laid by the Incan laborers, until we reached Victoria pass, somewhere around 14-15,000 ft above sea level. It is hard to describe the experience rounding the bend of that pass. First you gasp, and then you walk another ten feet and just laugh because it all seems too beautiful to believe--or perhaps it´s the lack of oxygen.

So that was the first three or four days. There are a couple more days of the trek to explain, but I have to leave it there. Each day deserves a complete chapter, but this is a blog, not a book. Besides, I can´t spend all my money on internet. There is still much to do over the next few weeks.

I know words are wordy and pictures are not, so pictures you shall have! I hope...

hasta la pròxima,

36 hrs in Cusco

I think I traveled for longer to reach Cusco than I will spend enjoying the great Incan capital. That is ok, because in six hrs I leave for an eight day trek (this is our vacation travel time of the summer, Yeah!). First to Choqueqirao http://travel.nytimes.com/2007/06/03/travel/03inca.html?scp=1&sq=choquequirao&st=cse

and then to Macchu Picchu. The three of us, and possibly this guy we met in the hostel who also made the journey to Cusco from Sicuani. His name is keecko! He was smart and bought a bike to get across all the road blocks. We met him having dinner in Sicuani (we stayed there one night) and then he passed us the next day on his new bike, and then he sits down next to us this morning as we eat breakfast on the roof-top terrace of the hostal in Cusco. Crazy small world.

much love,

36 Hours to Cusco

We finished our work in Arequipa and the plan was to head to Puno to check out the indigenas people living on the floating islands of Lake Titicaca. Nothing about this summer has been very ¨planned¨but so it goes, the best laid plans, even the not-best laid plans of mice and men oft go awry; they especially go awry when one is in South America. From Puno, we planned to head north to Cusco. The details were all worked out, meaning we bought the tickets to Puno. But then we learned that the strike that the indigenas people were leading had not ended and that all the roads were closed from Puno to Cusco. All the roads were closed from Arequipa to Cusco as well, but we also learned from some locals that the road blocks were very short at one point between Arequipa and Cusco. We decided to take the locals´advice and to believe the bus company that was running to the city where the strike was supposed to be only 5km deep. That means, the plan was to bus to the city, Sicuani, and then walk past the road blocks. After 5km, we would reach the end of the strike where buses would take us to Cusco.

Sounded simple enough but the road blocks turned out to be 50km long. It was a horrendous 36 hrs journey to Cusco. I walked and walked like a pioneer, I rode on motorcycles, hid in the back of a truck, paid kids to carry our packs on a tricycle, etc. We made the epic voyage with a Belgian, his Italian girlfriend, 3 Argentines, and a Frech dude. So much more to tell, so much. but the hostel guy is telling me to get off the computer.

Safe and sound. Signing off...

Sueños

The computer is not behaving with respect to photos so you are just going to have to imagine Arequipa through my very very brief post--if only there were time for more.

The city is nestled between an active volcano, el Misti that seriously rises into the sky like it is ready to burst. thirty sixty degrees to the west stands a great wall of snow capped mountains that were once volcanoes. The city is nicknamed the ´white city´because almost every building is made from the white lava (sillar) that has formed an interminable quary from previous volcanic eruptions. Pictures another day.

Our commute to school involves a short walk to the main street where we catch a taxi. In contrast to Lima, the air is pure and cool, the sky is clear and the sun is beaming down by 7am with intensity. I was waiting outside of a classroomthe other morning and a recollection of Provo came to mind. Why? I always thought the mts of Utah were kind of brown and well, not so grandiose. I think it was a combination of the air, the sun, and being on a campus.

After a hard day of work, we come home to our Arequipeña home with the familia Barrios. I couldn´t be happier with the set up. First thing, we get into our pajamas. Second, we help out with dinner, or sometimes just talk with the mom (Hermana Nelly) in the kitchen and then we enjoy an amazing meal followed by a couple hours of conversation over a variety of herbal teas. This is the life! I love our dinner table/tea time. This is what I love most about life, just talking with friends and family over an emptied table. Once we´ve covered all the bases, history, food, politicis, hobbies, literature, etc... we clean up and head to bed (or to drop a blog post). I´m kind of living my dream here in Arequipa. But it all ends this weekend and once again returns to being just a dream.

Sorry I don´t have more pics. There are muchos that I´d love to post but no time.Our morning walk

The view from our front door

Cooking the Lomo Saltado. SOOO GOOOD!

Peeling the papas for a little chicken al cial!

Carta

Carta is the spanish word for letter, but it is also used as ´card´as in playing cards. We have ¨played¨ a few cartas on this trip so far. I´ll get back to the cartas in a second...

We left Lima yesterday morning to head south. Our next destination, Arequipa. The medical school here is smaller, everything in Arequipa is smaller, hasta los taxis, y la gente so we expect the work to be a little less stressful--we´ll see tomorrow.

Our trip out of Lima, the gray city, consisted in a 5hr bus ride south along the coast. The poverty we drove through was horrendous. I´m no stranger to it, but I don´t know if it was the endless gray I´ve lived under for the past ten days or what, but this poverty was hard to see. I couldn´t see the hope in any of the shanty towns we passed. Maybe the difference is that I didn´t see the people, no faces,only my imagination to draw a miserable pictureof life in these pueblos.

We finally reached Ica where we took a taxi out to this little oasis five miles fromtown where the most incredible sand dunes rose high, high above the gloom of the coast. There, we were greeted with smiles, the people were happy and suddenly I found myself enjoying a small piece of paradise. We rented some sandboards for $3 dollars and spent the afternoon carving up these enormous slopes until the sun had well set and the dessert cold was blowing in. It wasn´t hard to imagine while walking up these dunes that I was in the Nimibian dessert in Africa or well, the Peruvian dessert in Peru.

We boarded another bus at 8pm to head down to Arequipa where we arrived at 8am. Just enough time to take a taxi to church for a little Sunday worship. Here is where we pulled out another ´carta.´ We spent a couple hrs one afternoon in Lima passing out surveys in a hospital as part of a project ofsome local investigators in Lima. We completed the same amount of surveys as other researches did in twice the time it took us. We chalked it up to the international card. I also credit it to my aptitude to just walk into anywhere when I am in a foreign country. That´s how I ended up in the office of the director of health services for Andhra Pradesh when I was in India. OK, other cards played, the gringo card-no understand spanish-Rochester card, people oddly know more about the school here than I did before I came. Now in Arequipa, it was time to play the ´mormon´card. A friend inLima has a boyfriend, who´s family lives in Arequipa. The mom was baptized four years ago and hethought she would love to meet us. So we went to her house for lunch and after being in the home for five minutes, they refused to let us find a hotel or hostel. The family is so, so nice. And the house is great. I took a hot shower with pressure and all for the first time today since I left DC. We will be here in Arequipa until our work is done. Probably three or four days.

Lima

We´ve been working from 8am to 8pm six days a week since the day I arrived in Lima. The
pictures I posted in the last entry suggest otherwise, sorry. Today, we finished our work at 6pm. Just enough time to pick up our washed clothes, grab dinner, pick up a gift for our host family, and pack for our travels tomorrow--oh, and Zach and Ronin went out for the night with some of our limeno friends. I thought I´d get to bed at a decent hour but it takes so long to plan things! I am just now getting to the blog.

I ate cow hearts (anticuchos) last night because our lima peeps wanted us to enjoy some of their favorite cuisine. Just wanted to make a note of that. What else do you want me to say, pues. Thanks!

Our last focus group in Lima!

The waiting areas are always full hasta the hallways in this hospital

Outside of the Hospital, I wish this guy replaced the hotdog vendors outside of the school´s hospital in Rochester.

He was actually very happy that I asked to take his picture. Seriously!

Debbie thought the food was...hilarious

It was so good, Leslie called everyone about it

We met up with Rochesterians Tuesday night for a late dinner at the famous, Astrid y Gaston ( unfortunately, they were just stopping in for a day, we think?)

Una foto, una foto

Hola desde Peru. Why am I here? I planned on writing a post before I left to explain what I plan on doing here. The long and short: we are a mobile species. The more educated, the more mobile. This is great for the educated but the uneducated, surprise, surprise, lose. So doctors are leaving Peru to practice in better places, like Rochester. I am here with two colleagues to find out why medical students choose to stay and practice in Peru or why others choose to leave their homeland for ¨better¨land. Oh no, my Spanish is already ruining my English, ¡que horror! Seriously, that makes me sad, pero bueno, asi es.

The other part of the study is that almost a third of all doctors currently practicing in the US come from other countries. I attended a meeting a couple months back where the New York congress presented a new bill to excuse visa regulations for any foreign doctor as long as they practiced in under-represented rural or urban areas. Really? There is a lot of ethics to pull out of this but I don´t have the time, ahorrita.

So here I am in Peru, surveying and meeting with students in focus groups to understand their perspective, and to understand if they understand what they are bargaining for when they sign up for a residency in the Johnny (USA). Understand?

A few pictures outside of the University, Enjoy!

This is a poster in the University of San Marcos of Medicine. Those lines are SO latino. Gotta love how romantic the culture is.

Eating a local treat, Picarrones. Yes, they were delicious.

Pigeons never go hungry, 1st or 3rd world.

Plaza de Armas, Lima´s central plaza, behind is the, Hotel Bolivar

Yes, a little discotequing, of course. The best part was when the power went out around 12am throughout the entire district. I love Sur America!

Wouldn´t be Sur America without cathedrals