Deep Thoughts from the Chicken Bus

The more I learned in medical school, the more I felt I didn't know. I've had very few moments when I thought to myself, Gee I know too much for my own good. Well, I had one of those moments this weekend while riding an overcrowded bus. These "chicken" buses, at least the ones I've been on, don't have cages of chicken on them. I guess they did before. They are actually yellow school buses that are painted in various bright colors. On the front they have their origin and destination, making them pretty easy to figure out. (Unlike the time Joe and I took a bus to Manuel Antonio in Costa Rica and kept our fingers crossed we would end up at said destination).

Anyways, so the moment. The bus continued to fill w/ more and more people crammed like sardines. People sitting in chairs, and people in the aisle on top of each other grasping for dear life. As I was standing there, on our way home from, the word froutterism, UNFORTUNATELY, popped into my head. I was cursing First Aid and how the example took place on a crowded place like a train or bus. I was praying to high heavens that this would not happen. Of all the things to remember... Luckily no harm no foul.

Other thoughts:

• Dear El Salvadoran women, how do you wear black eyeliner in this heat? I, MAYBE, put on eyeliner if I'm working in an air conditioned office. Maybe.

• Kind sir preaching about world famous leaders. Will you shut the hell up if I buy your book that features Buddha and Adolf Hitler on the same page? These people obviously are not listening and saying, las palabras de dios, may grab their attention, but they still don't want your book.

• Thank you muchacha for holding our bags in your lap while Scott and I are grasping for dear life on the bus. We do like your Guns 'n Roses tank. We wonder if you were at the same concert as the Doctor.

Snowstorm in El Salvador

This week I'm working w/ Wendy, a first year Ob/Gyn resident, in Patologías del Embarazo. Most of the patients we receive are women who complain of bleeding early in their pregnancy and end up having miscarriages. We occasionally get a patient with placenta previa. This week we had a 15 year old girl (G1P0 - for those of you who speak the same language as me) who was sent from a town called Sonsonate...

This was the ultrasound that accompanied her...

This ultrasound shows what we learned as "snowstorm" appearance, indicative of a molar pregnancy (hydatidiform mole).

Since the Hospital Nacional San Juan de Dios does not have the equipment to suction out this molar pregancy, we had to send her to the capital, San Salvador. There they will also determine if the molar pregnancy was complete or incomplete. So between yesterday and today, we got her beta-hCG quant and a chest x-ray (to make sure no metastasis occurred) before sending her on her way. Her quant was in the 400, 000 level. CXR was normal. After a phone call and a signature from the attending, our patient left for San Salvador.

Que lastima! No tengo mi camera!

So yesterday, I casually mentioned to Mario, Sr. that I needed to learn la palanca de velocidades (stick shift). I think Senor Gritz would be appalled by my lost ability to use (and conjugate) the conditional tense. Actually, all the other tenses other than the present and preterito.

Anyways, so Mario, Sr. started teaching me immediately... and I said, "No, otro vez! Manana?" Hahaha. Surprisingly, he remembered. And this evening I had my very own lesson in driving stickshift. In spanish. En el campo - the countryside.

THANK GOD I had a lesson of the basics w/ Joe a couple years ago. Luckily I didn't hit any El Salvadoran child or puppy.

Mario, Sr. decided to teach by letting me drive to the countryside to pick up Catalina (the sister of Mama Chave's first husband). We met her sister, Paz, who lives by the train tracks at a higher altitude than El Congo. It was quite a difference from the living conditions here at Casa de Mama Chave. The house resembled a wooden shed held up by some miracle of God. It smelled of camp fire and there were dogs chasing around roosters. Everyone always introduces me as "este Melissa. ella doctora (as I usually interject w/ No, no, en Mayo, Doctora) ... ella mejora amiga de Jackie". They are the sweetest.

On the ride back to El Congo, we took the scenic routes and Mario, Sr. and Catalina pointed out all the small churches. She also bought Scott and I pastillitos (sp?). I think they are my new favorite thing. They are fried dough w/ shredded lettuce (and not sure what else) inside. They reminded me of little tiny empanadas. The vendor puts about 6 of them in a small plastic bag filled w/a tomato sauce mix. HEAVEN.

The one time I don't have my camera on me... so much I wanted to capture. So, I told Mario, Sr. that I wanted to go back to see Paz and the churches, this time with my camera.

I may just start smoking...

... so everything I want to say anything, anything at all, I'll just suck in the nicotine.

Apparently, I'm wrong about everything so I've succumbed to being quite the mute these days. Or just a crybaby. Sometimes both. Overly sensitive, quite possibly. Misinterpretation of these minor jabs, sure. My saving grace is Labor and Delivery (doubt I'll be saying that in a few months) and the most welcoming and warm doctors at the hospital. 2 more weeks I will be back in my dirty city and I can be my chatty self and perhaps laugh again.

Until then, light me up. I guess I would probably have to buy a pack first.

coffee, beer, and ice cream

Fridays have become special days for Scott and I. Last week we ventured to El Lago. Today we decided to hit up some Mayan ruins in Chalchuapa. Welcome to Tazumal!

Ok. Having major problems (still) with uploading pictures onto blogger. Not sure if it's blogger or 3WC internet. Anyways, between Scott's Central America Book, Lonely Planet, and the Cabrera-Barahona family, we've been able to get around El Salvador with ease. We took the 202 from El Congo into Chalchuapa and walked a few meters to the ruins (you can see pics on FB, ugh so annoying). This was the first Mayan ruin I've ever been to so I was pretty excited. The entrance fee was $1 for natives and $3 for extranjeros. I swear if I didn't open my mouth (or if I was fluent in Spanish) I could probably pass for a native. Today at the market, while I was trying to bargain down a pretty sweet hat, the vendor asked if I was from here. To his dismay, I am not and had two guesses- Hawaiian/Chinese or Filipino. Ding!Ding!Ding! The funny thing was he pointed out how my eyes were different and proceeded to pull back the corners of his eyes and say "chinky". I'm pretty sure Joe would've loved to be there for that moment. I honestly don't even think I have asian eyes, but es muy bien.

Scott and I met this endearing American, Tyler, at Tazumal. He is a 26 year old from Portland, Oregon who spent almost a year teaching mathematics and sociology in Columbia. Once that gig was over, he decided he wanted to work his way up back home. He went to Panama, Peru, Costa Rica, Honduras, Nicaragua, and now finds himself in El Salvador. He will be meeting his parents in Guatemala next week. I give him a lot of credit. I can live vicariously through him, because I'm not sure I could be a lone traveler for that long.

He told me that when he gets really frustrated in his travels there are 3 things that make everything all better: coffee, beer, and ice cream.

I was thinking today about what my 3 things would be and I came up with: coffee (coffee is pretty fantastic), shopping, and a hug. I got all 3 today :) Coffee I've been able to have everyday. Finally, we got to go through a pretty cool market including a lunch that cost us $1.50 each. And when we parted ways w/ Tyler, he gave me a hug goodbye. I haven't had a hug since I left on April 3. I guess I didn't realize how much of a staple that has been in my everyday life. I'm hugging everyone when I get back!

Muy triste....

Yesterday, we received a mom in el parto (short for L&D). She came in with an X-Ray of her thorax. A doctor who sent her was thinking she was having twins because she was large for her gestational age. Nope, not quite.

Mama had polyhydramnios because her baby has what we call "Anencephaly". The Central Nervous System fails to develop completely (see the wiki link for more). In the States, women of reproductive age are encouraged to include folic acid in their diets. Folic acid has been shown to reduce the risk of Neural Tube Defects. The prenatal care down here is inconsistent. Sometimes the moms are able to get appropriate prenatal care, but in this case she wasn't so lucky. One of the residents told me that anencephaly is common down her, but not sure why.

Pretty sad day. I was thinking of how I couldn't begin to fathom how the mother felt. After carrying this baby for almost 9 months and to not bring her home. That is the rough part of this field. It can go from one extreme to another- the happiest of moments to the most heartbreaking.

We did it all by ourselves!

Scott and I decided to venture back to El Lago on Saturday. On our own. We were gonna walk there and catch the bus on the way back. I was kinda wary about walking there b/c we don't have a map and we had only been there once (being dropped off by Mario, Sr.).

So, we're walking. In town, the bus to the lake passes us by going the other way so we definitely knew the buses were running. Score. We continue beyond the main street and cross the overpass above the main highway. You sure we're going the right way, Scott? We were walking for about 20 minutes or so and the Coatepeque bus hadn't passed us.

Random moment: There was a bright orange hatchback that passed us and a guy leaning out of the window whistles and then says something in Spanish. Scott- What did he say? Me: I have no idea. Maybe $5 for a blow job, lady? But maybe he was commenting on my defined calf muscles. I did work out before we left for the lake.

Later when Scott asks me what I was thinking on the walk over, I tell him, "This guy has no F****** clue where we're going." Thankfully, the bus finally comes and drops us off lakeside. We stop at a small store, Scott wanted a cold dessert, and I needed some soda. The lady asked if I was native to El Salvador and I say no. She said I have similar skin tone to the people here but ojos diferentes. I imagine if Joe were here, he'd be sure to interpret that as, She just told you that you have chinky eyes.

God Bless America...

...is what one of the surgery attendings told Scott and I. He was asking us about the USMLE and that he eventually wants to move to the states (even though he has it pretty good here). He spoke of his brother and sister who are living in Idaho and L.A., respectively. He stated his gratefulness for the opportunities America has given them. Scott mentioned the First Aid series and those books are apparently a hot item. In fact, Scott brought it in yesterday to show Dr. M and another physician bee-lined it from the O.R. and asked if he could have it. The neurosurgeon Scott was working with told him to not leave that book unattended or someone would steal it. I guess we don't realize how good we have it.

But, it can go either way. The doctors here get to truly practice medicine. I need an X-ray. It is done. I need bloodwork. You got it. You need to take these antibiotics. Patients listen. The doctors are not taught, in medical school, to "view each patient as a potential lawsuit" and to make sure every minute detail is documented in a chart and in the dictation. They are not constantly on the phone fighting with insurance companies to reason why the CT needs approval or why this patient needs to take this medication. And the paperwork. The endless paperwork. I'm not looking forward to that aspect. I have nightmares of charts stacked up to the heavens.

However, after working for a week in Santa Ana, I wouldn't trade my spot for the world... for now at least. Talk to me June 2011. Haha!

Well, I know one thing for sure- GOD BLESS AMERICA for BASEBALL! And God Bless Joe for spoiling an American brat that is yours truly. The gift of mlb.tv will get me through the nights (since it is not advisable I be out after 6pm). Te amo mi prometido. Te extrano.

El Lago de Coatepeque

Thank you Jackie's cousins, Nancy and Pedro, who took us to El Lago today. An old volcano turned lake, this beautiful place is both a home to many (Jackie's dad grew up here) and a popular tourist spot. Pictures can be found on facebook. Me and the blogger uploader are not friends. Could be the Central American internet.

We met some Americans at the restaurant we were at, Rancho Alegre, who were very friendly and were wondering why Scott and I didn't go to Rutgers as we are native New Jerseyans.

If Jackie and I were to pro-create...

... we would have a son thriving as an Infectious Disease Specialist, nicknamed Eddie.

I'm pretty sure one of the surgeons sighed, "Oh females," as I got super excited about seeing my last name and Jackie's last name next to each other. And I'm pretty sure it was her uncle.

No lap choles in sight!

No offense to my gen surg friends of course ;)

Ohhh it’s NaLa not NaNa…

I should've known right then and there that me hearing "Nah-nah" as the name of the house dog was reaffirmation in choosing Ob/Gyn. I guess it can also mean I'm twisted and sick. Nonetheless, today I fell in love all over again.

Unbeknownst to Scott and I, we were not participating in the gastrectomy (praise Jesus!) today. Instead, Dr. Cabrera handed us over to our areas of interest. Scott to Neurology/Neurosurgeon and I in Labor & Delivery! As soon as I entered the ward, my eyes lit up and I was ready to rock-n-roll. Within 20 minutes we were rolling a mama at 30 wga (weeks gestational age) into Cuarto del expulsión No. 3. Here the women in labor are placed in this elongated hallway titled Trabajo de Parte (fancy for “Labor”). It resembles the hallways found in emergency rooms where patients are placed when all the rooms are taken. Once they are ready to empuje, they are rolled into a cuarto del expulsion. These are located in a huge room on the other side of the ward which are divided into 4 sections. So, multiple vaginal deliveries can be going on at once. Then there was a tube tying called an esterilización, then a cone biopsy of the cervix, and then I got to first assist a c-section! Love it.

One of the attending asked if I was gonna do turnos aka night-shift. I’m gonna opt for no gracias. I will definitely bring that term to the states come June and dub “night-shift” or being on call – TORturnos.

Today, the country has one of the world's highest homicide rates...

Archbishop Romero

This was the first picture I took in El Salvador - it's a banner that is seen as soon as you exit the airport. I didn't know what compelled me to take the picture. I hadn't had the chance to look at it let alone try to translate the words. But, each day I like to google "El Salvador news" and someone else's blog came up posting an article in the Washington Post about a former military captain, Alvara Saravia who has decided to provide details after all these years.

I didn't realize that Scott and I arrived her just a week after the anniversary of Archbishop Romero's assassination which was the beginning of El Salvador's 15 year civil war. Jackie gave us a briefing on the history before we left about the conservative party and the leftist guerillas...

...but gotta go to the hospital. Click on the link to read the very interesting article!

Gimps y Yo on a mission...

Scott and I got back from the hospital today with enough time to take a stroll through the main street in El Congo. We were on a mission to get beer and wine. Surprisingly, we were not hassled to buy anything from any of the vendors. Just some looks wondering what this gringo in a cast was doing hobbling along in their town.

To our dismay, a 6-pack of Pilsener was out of budget and there was no boxed wine (Scott was really disappointed about that). We picked up a bag of chips and were appalled at the calories per serving. A bag, roughly the size of those $0.99 dorito bags at wawa, held about SIX servings at almost 300 calories per serving. Put that bag down! Scott is convinced that there will be a huge need for Statins in this area very soon. Everyone here is well-fed!

On the walk back, I realized what the street reminded me of – Market Street! Random stores playing loud hip hop music, selling DVDs, TVs, and hubcaps. I debated on buying a set and shoving it in my suitcase. Maybe if I have extra bisto. In addition to the small shops, and even medical clinics, there was a store that was selling tile for the kitchen or bathroom, one selling toilets, and even a cell phone store. I had to pull Scott along as he stopped in front of the fried chicken place (equivalent to Crown Fried Chicken for those of you familiar with that establishment) mesmerized by the intoxicating aroma of fried chicken. We had to get back to put the two botellas of vodka in the freezer.

There is no Nighthawk in Santa Ana

We took LM to get the standard chest x-ray after central line placement, which was down the hall. Instead of ordering a portable CXR, the patient is the portable entity. No one was wearing protective shields and the tech had his 3 year old daughter washing her hands in the sink next to the machine. Mario was called in to read the XR. We followed him in and I noticed a familiar aroma. I was taken back to my last semester at Loyola - hours spent in the photo lab processing film and developing prints. Wow they develop their own X-rays right then and there. Scott was right, ”I am assuming this film isn’t coming up on the computer.” The line was in its place and no signs of pneumothorax.

With a 2 hour time difference and having gone to bed 10pm El Salvadoran time, I woke up bright-eyed and bushy tailed at 5:45 this morning. Got into the shower and let me tell you the Castaneda bathroom is hooked up. Heated shower water is unheard of here, but we have it.

While Scott and I were reading out on the back porch Mario, Sr. comes out to tell us something. I was trying to make out “desayuno” (aka breakfast), but somehow Scott was able to decipher “hospital” from his message. I guess Fatty wanted her beans, right Greg?

Apparently, Mario got called into the hospital today because a patient of his was very sick. The 3 of us scarf down some eggs and beans and rush over to “Hospital Cader”- one of 3 hospitals/clinics Mario covers. Sorry, Ma didn’t make it to mass today.

We enter this baby blue painted building, pass through some hallways and arrive at LM’s bedside. He is a 72 year old male diagnosed with gastric carcinoma. He complained of severe abdominal pain in the middle of the night. All 45 kilos of him was writhing and moaning in pain. I noticed I could count each of his ribs and clearly distinguish the 3 parts of his sternum. Mario couldn’t get a blood pressure and we felt his pulse was faint. Outside the room was his family. Worried, upset, sobbing.

LM was moved into a different room where we could put in a line. The landmarks on his neck were so clear that the IJV (internal jugular vein) could not be missed. With his head turned to the right, his sternocleidomastoid was well defined, as if I had my Netter’s open. Just this time, a layer of skin was between me and seeing the muscle fibers. Mario handed me the guide wire and I immediately had flashbacks of when I placed my first central line. Don’t ever ever ever let go of the wire. Ever. I watched him prep LM and proceed, with precision, and gaining access on the first stick. No ultrasound guidance to ensure you are aiming for the vein and not the artery. No huge blue sterile sheet covering the patient and no huge blue sterile gown causing you to sweat and fog up your plastic face mask and rendering you blind. Just the basics. Sterilize the area with iodine, look at your landmarks, and just do it.

If you look carefully, those bottles on the right are Starbucks Frappucino Bottles.

Applying the Nike slogan to central line procedures in the U.S. probably wouldn’t fly well with the insurance companies, lawyers breathing down our necks, thick-necked patients, and germaphobic/antibiotic resistant Americans.

Primer Noche

I must've brought the rain. It's rained twice since we got here, but it does have a nice cooling effect. After almuerzo (aka lunch), I took a long nap. Between being tired, full, and the heat/humidity I had a nice slumber.

When I woke, Scott and I joined the main household to chat- mostly to soak in all the Spanish we can. We met Mario's sister-in-law who said Jackie and I looked alike. We do get mistaken for sisters often. (Side note: at customs, the hombre was confused because my last name is "Suarez" yet I had an American passport. He kept questioning, "Latina? Latina?" Nope, Filipina. Scott interjected with "She's American" and the poor guy was confused. "American with the last name Suarez" Yes, I know. Hard to believe. Where is that imnotmexican.com site when I need it).

Mama Chave is Jackie's abuela who gave us some pupusas for dinner- which are akin to corn tortillas, soft and filled with cheese and or beans. I knew Mama Chave was mayor of El Congo, but tonight we learned she was mayor- or Alcadesa- for FIFTEEN YEARS! Elections are every 3 years. I think it's amazing she was elected 5 times. When she started, the country was undergoing a civil war at the time. Mario said she was running for office while he was in medical school and remembers fondly of his classmates chanting "Ma-ma Cha-ve, Ma-ma Cha-ve" to him.

Tomorrow is Easter Sunday. I promised Helen I'd go to mass. And I promise to take pics so I can post them. We start work on Tuesday and I'm itching to get back into the O.R. as crazy as that may seem!

Found a use for this blog after all...

This blog was originally inspired by Laurence Ross who always has the ability to share in life's... well I guess just life. Good and bad. We were both bitching about our lives, as per usual, and it was suggested to him that he go to a junkyard and throw glass bottles (see first of 3 entries- hah!). Sometimes I sign for things due to my obsessive compulsiveness and end up with things like a latent blog. But, it's back up because I have an excuse to write- on the plane ride to El Salvador, I was thinking I wanted to keep a blog of my month here. So, instead of creating a new one, I figured I'd awaken this bad boy up.

Before I started medical school, I randomly found myself in Costa Rica with Joe. Mike DeShields extended a casual invite to "come visit whenever". So, that's what we did. We bought plane tickets and flew down to Central America. No plans and not even an address. Just directions, in Spanish, to his place.

4 years later I find myself back in Central America. I took a shot in the dark and asked Jackie if her uncle, a surgeon, would mind Scott and I to come down for a month and complete an elective. Thanks to Jackie and her uncle, Mario, Scott and I are spending a month in El Salvador to end our final month as medical students.

Mario picked us up from San Salvador and when we got "home" we were greeted by the sweetest family - Mama Chave, Mario, Sr., and Nancy. Almuerzo was just what I needed and Jackie called to check in on us. Feeling at home already.

Stay tuned for pics...