My Week in Honduras

Pinares, Honduras

So… I am writing this after returning from the mountains of Pinares. It seems surreal to think that I was just there. I’ve been wanting to do a medical mission for quite some time. Things just never seemed to work out. But in October, the stars finally aligned and I was able to sign up for this trip.

A little bit of background. My residency is part of VCU School of Medicine. VCU has had an ongoing relationship with an organization called Shoulder to Shoulder for many years. Shoulder to Shoulder in turn is an organization that has spent a lot of time trying to help the people of Honduras by assisting them with sustainable economic and medical assistance. So as part of this program, they have several clinics established and they have a program for going into schools to do a number of health screenings for kids.

Throughout the year, different schools and different organizations send a brigade of people both medical and non-medical to go out to work both in the clinic and in going out to the schools. VCU sends out a group 3 times a year. Our residency sends a group out in February.

And that’s how I ended up on an amazing journey into a world I never thought I’d see.

S2S

All of this is made possible by an organization called Shoulder to Shoulder. S2S is an organization that was started many years ago.

Their mission is to help the rural poor in Honduras. They go about this in many different ways… they try to incorporate a combination of economic, agricultural, public health, and medical aid. They have set up multiple clinics throughout the country, some scholarships, various public health projects, and coordinate brigades from different organizations in the U.S. They have a group of interns that work with them a year at a time; and they also have a great brigade coordinator named Marvin who helps the brigades set things up and work through issues while in Honduras. They also serve as key liason to the Comite.

The Comite

The Comite is an organization of local community leaders that help guide the direction of aid to the villages in the mountains. They are led by one local leader in particular by the name of Don Quintin. He is a small man with a gentle manner, a tremendous heart, and a smile that can fill an entire room. He is really something special. It’s interesting, because I had the chance to visit his house. To get there I have to take a short… but very steep walk. When I get there, I am soaked and pretty out of breath. I’m also a little shocked. I’m not sure what I expected. But I know that I did not expect him to live in such poverty as well. When I think of political leaders… even in small communities, I tend to picture some degree of corruption; usually a sense that they are ensuring that they are taken care of first and foremost. I don’t know if Don Quintin is in fact lining his pockets, but because there is so little, it doesn’t show… but somehow I do not get that sense. Their house is a few cinder blocks with a clay tiled roof, and all dirt floors. There are 3 rooms; one for the kitchen, one for storage, and one for everyone to sleep in. That’s it. The house is on a small shelf on the side of the mountain that amounts to the size of my family’s living room. It’s truly humbling. From what I have heard, the comite does a lot of good, but can also be somewhat frustrating to work with due to competing interests, self-interest, and an occasional inability to see the big picture. Whatever the specifics and complexities of how the Comite operates, I suspect that Don Quintin is the kind of leader that all of us wished we had in our own communities.

The Team

As I said before, our residency sends several residents every February. Our team is made up of 5 residents, 3 attending physicians, and 4 nurses from our office. We also have 2 docs from Georgetown, 2 volunteers from the free clinic, 10 volunteers from an organization called Thundermist. Thundermist is an organization that has clinics set up to work with the uninsured in the New England area. They were integral in setting up the clinic in Pinares and are a big reason why we are able to do what we do. In addition, we have 5 Honduran translators hired by S2S to help us throughout the trip. So all said and told, we have 41 people in our team.

It’s an eclectic bunch, because we are bringing together 3 groups that knew the people in their own group really really well prior to the trip and having them all work together with the other groups. The first 2 days in country takes a little getting used to for us, but we all end up quickly working very well together. It’s amazing to see what happens when people come to a place with a sense of higher purpose and when they see the need for working together. We all gather together in a town called El Progresso where we stayed for a night, and then took a chartered bus into the mountains for the week.

The Town

Our clinic is in a little town called Pinares, named after the fact that we are surrounded by pine trees. It is a mountain town that is fairly isolated. The closest big town is Esperanza which is still about an hour and a half away. You will likely not find it on a map. Many of the towns in the mountains are not on the maps in fact due to being so isolated. The clinic in this town has been around for many years and is manned by a dentist and occasional brigades. Pinares basically consists of one little rest stop with a small diner attached to a small building that has a few dorms, an outhouse, 2 other little snack shops, and a few small houses… all at a crossroads of 3 dirt roads… plus the clinic. That’s it. That’s the town. The people then live spread out across the area in little isolated huts. Pinares is the very definition of the word sparse. Yet this is still quite a bit better than what is available at other places up here in the mountains.

The drive up to the town… is… an adventure. The first half is quite nice. Beautiful views… friendly people. But once you start climbing the mountains, you enter so many different elevations and different pockets of ecosystems. It’s interesting going from temperatures in the 80’s with lots of heat to immediate 40 degree weather with a stiff breeze. The roads are incredibly bumpy… very dusty… very narrow… with huge drop-offs on the sides. Just getting to Pinares without throwing up feels like a huge achievement.

I’m not going to lie. It takes some getting used to. The town is really really small. And the people there live in very poor conditions. I know it’s trite to say… but we really take a lot for granted in the United States. There is dust everywhere. Everyone in the town is covered in it. At the end of every day it’s hard to imagine not taking a shower to get the dust off. Yet you realize that most of the people here do not have that luxury because they need to conserve water.

The “hotel” that we are staying in is fairly tight. It has 10 rooms with 4 bunks cramped into most of the rooms. Each room has their own bathroom with a shower, a sink, and a toilet. It is a really tight squeeze with fairly unpleasant smells, compounded by the fact that you can’t put your toilet paper in the toilet due to the risk of clogging the septic tanks. However, this is the lap of luxury in comparison to what the people of Pinares live in. It makes you really grateful.

The Clinic

The clinic is a nice building with 2 exam rooms, an OB/Gyn room, a Dentist room, a mini lab, an office, and a mini pharmacy. It is manned throughout the year by a young lady named Nora who is the equivalent of a medical assistant. Then 3 times a month, a brigade of doctors comes to see patients. People for miles around know when we are coming. For 4 days, they pour into the clinic to be seen and to get soap, shampoo, toothpaste, and toothbrushes. In the mornings, you see people waiting outside the clinic hours before the clinic even opens. Some people walk 3 and a half hours just to get there. For the most part, the complaints are fairly simple; lots of headaches, stomach aches, joint aches, and URI’s. In addition, there are many OB/Gyn visits. The hygiene supplies are a big part of what they are coming for. But there are plenty of more difficult situations as well. We saw some significant heart issues; anxiety; tumors; hernias. Things that a 2 room clinic with a few volunteer family docs is just not equipped to handle. When that happens, we write a referral letter for the hospital in La Esperanza, but that isn’t an easy proposition either. It takes money to get to Esperanza and to be seen at the hospital. There are a lot of ways to help cover this, but still… it’s not an easy thing.

The Children’s Health Initiative

There are about 50 kids in the town of Pinares alone. Half of them are school age. There are also many kids throughout the mountain villages.  In addition to providing medical care at the clinic, we send out groups to remote schools and set up a series of stations designed to screen kids for preventative health issues, provide some preventative treatments, and also keep track of their progress.  In all, we end up seeing around 350 kids at these local schools over a 4 day period.

This involves multiple components… it begins with a pretty extensive hike through the mountains… some of these hikes take a significant amount of time and cover very large elevations. Some locations, we end up riding in the truck to get there. The actual work itself goes by quickly and is pretty fun and quick. It’s funny watching the kids approach us shyly… and then begin to warm up to us. But it’s also hard to watch them watch us eat our lunches because they are hungry. It’s a tough duality of being here… so much simplicity and joy… accompanied by so much in the way of sad circumstances…

The People

The people of Los Pinares are truly kind and generous. They have a patience that is unfathomable. They have a happiness that I think many of us in the States would have a hard time truly understanding. I found that every single person I met was eager to greet us and welcome us to their community. I noted that in the States, we are so consumed by this notion of privacy and personal space. I am no different. I certainly have immense walls and barriers up to keep myself isolated. But in spending time here in Honduras, I wonder if we have cost ourselves a sense of community in the process. In the States, you rarely say hello to one another as you pass. Just about everyone I walked past, acknowledged me in some way. In addition, I don’t think I could point out a single act of rudeness on the part of a Honduran person, my entire trip. I can count 10 acts of rudeness in the U.S. in an hour alone. What the hell has happened to us as a country?

The Children

It’s pretty cliché to say that the kids in a particular part of the world are amazing. But it is in fact true that the kids in Honduras are pretty amazing. They all tended to be somewhat shy and stared an awful lot. But once they warmed up to you… they were all so sweet and loving. In Pinares, I’d say 99% of the kids were covered in dirt or dust. Seeing how they lived, it’s no surprise; just because they really had no way to escape the dirt.

The kids in Honduras absolutely LOVED having their pictures taken. They could be all shy and timid, but the minute a camera came out, they seemed to come to life and posed for the camera. Then their favorite part… seeing themselves on camera… just let there be one of them closing their eyes during the camera… they go completely bonkers laughing. It was so cool to watch.

The Food

We had all of our meals throughout the trip taken care of. It was mostly tortillas, beans, eggs, avocado, rice, and chicken. It was actually… quite good… and plentiful. I didn’t get to eat as much of the fruit here as I did in Costa Rica, because the water isn’t as clean. It’s crazy how much we take for granted. For crying out loud, we have water filters in our houses, because we think the water has a “funny” taste. But really… we could drink faucet water all the time and none of us would have to worry about it causing problems. Not true in Honduras.

The ladies who cooked for us in Pinares did so with great hospitality and generosity.  Truly... we ate like kings... when you considered how the rest of the town ate.

The Work

So on a given day, we woke up and had breakfast at 7. Then we either left to go on a CHI or went up to the clinic. There were a lot of people that wanted to take the long hikes to the CHI’s. So I ended up spending most of my time in the clinic.

The clinic is not normally staffed by a doctor. There is a “nurse” who is actually more of a med assistant who is there throughout the year. She triages any immediate issues that come up. When brigades of doctors are there, she opens charts, takes vitals, and cues patients up to be seen.

There is a dentist that comes in from out of town. She usually comes up when the Brigades are here. It’s mostly about tooth extraction. There just isn’t enough time to see everyone and do proper fillings.

During 4 days of operating the clinic, we saw a little more than 300 patients. This is an average of 75 a day with just 2-3 doctors. This also does not include the patients that came through just for dental care. I spent most of my time in the clinic working in the Pharmacy. Part of this was because I speak some Spanish… and the pharmacy requires explaining the medications… how to take them… writing the instructions… and answering any questions. In Pinares… working the pharmacy also involves substituting drugs that the docs WANT to give… with what we actually have in the pharmacy. Sometimes, this is simple… sometimes this takes a lot of creativity. When we ran out of Tylenol… I had to give out children’s liquid Tylenol with instructions to take enough to make a difference.

I also was responsible for giving out goody bags with shampoo, soap, toothpaste, and toothbrushes. This is… a tricky process. People want more… and definitely need more… but then… you have so many more people coming through… and you’re not sure if you’re going to have enough to go around. In fact… on Day 4… we ran out of shampoo and big toothpastes… It was hard to have to tell people that I didn’t have any more shampoo for them… I started giving out toothbrushes by the handful, because it was the only thing I had left… Truthfully… how can you turn down people asking for something as basic as soap, toothpaste, and shampoo?

One of the things I really like about working the clinic is that I get to interact with every single patient that comes through the clinic. I try to find out where they are coming from and what it took for them to get here. I also have to give them instructions on how to use their medicine. This can be a lot more difficult than it would seem. The literacy rate in this part of the country is not great. It requires a lot of creativity.

I also really enjoyed hearing each and every one of their stories. It’s amazing to see the lengths to which people go through to receive healthcare… when it is not readily available. We really do not appreciate our healthcare system.

The work is pretty amazing. Each day is sort of a mix between excitement and nervousness. There is so much uncertainty in terms of what might be coming through the door. There is a constant scrambling on your feet to improvise and make do with what you have. There is a constant search to find the best ways to help each person that walks through the door. There are a ton of really amazing patient encounters and interesting cases… I could end up writing for an entire lifetime on some of those encounters. For now, I think I’ll save them for other posts. Regardless of the specifics… each day is filled with incredible challenges… lots of learning… and tons of work… and a lot of variety.

But the end of each day feels the same… a weird confliction of satisfaction and frustration. Honestly, it’s clear that what we do is a band aid… though I know there are things we are doing that are moving towards long term sustainability… there’s this nagging feeling that we’re not doing enough. It’s hard. I keep telling everyone, I feel like the end of Schindler’s List, when Schindler keeps thinking of more that he could have done. I feel haunted by all the things we couldn’t do. I think about the soap, shampoo, and toothpaste that the people here need. I think about what's left of their shoes. I think about the clothes that do not fit. I think about the meds we did not have. It’s a frustrating feeling. And sometimes, I find myself haunted by it in my dreams.

Heroes

The truth is… it’s not people like us that make a difference in communities like this. It’s the commitment of others that truly have an impact. The highlight of this trip by far was meeting the heroes involved in saving this part of the world.

Isabelle – Isabelle is a controversial figure. She was originally from Pinares… but left the area… somewhere along the way, got married, had kids, and then left her husband. At some point, she went to Israel and worked as a domestic aid… saved up her money… and came back to Los Pinares and opened up a fruit stand. With the money she made and saved, she then turned her fruit stand into a restaurant… recognizing that the crossroads was an ideal stop for people who were traveling to stop, use the bathroom, and get a bit to eat. One day, there was chance encounter with a woman from Thundermist who happened to be traveling through the area with a person from shoulder to shoulder. The two started talking about the need for a medical clinic in the area. At the end of the encounter… a tentative plan was in place to begin talking about setting up a clinic… this resulted in the Comite forming to help the clinic management and the brigades that would be coming through. This resulted in housing for these brigades being set up on the part of Isabelle. This resulted in more jobs being created in the crossroads of Pinares. This resulted in an increase in buses stopping at the crossroads. This is how it came to be that gringos from the U.S. make their way to the remote mountains of Honduras 3 times a year, bringing medical relief, preventative health measures, and a needed infusion of income to the community. Let’s be clear. Isabelle is a businesswoman. She does not do this for charity. She certainly is not paying her employees a king’s ransom or showering her profits amongst the community. Nor do I believe that is what she should do. Her singular focus is the capitalist dream played out. It is everything capitalism is supposed to be able to do. She is… in my mind… an amazing woman.

Marvin – is for all intents and purposes the Shoulder to Shoulder concierge and ambassador. He makes all of the arrangements for the brigades coming through. He oversees so many of S2S’s programs. He picks up brigades and escorts them through the country. He works with the Comite and the various schools that we go to. Nothing would get done without him. All of this wrapped in the biggest smile and heartiest laugh you could ask for.

Don Quintin – Don Quintin is the head of the Comite. He is a small man, but extremely wiry… and with a genuine smile that warms your heart. The Comite is a situation that just seems ripe for corruption… and I’m sure on some level there is some degree of it. These are not elected officials. How these individuals came to be chosen is somewhat dubious. Yet… Don Quintin… is that rare leader these days… one who puts his people first… ahead of his needs. I visited his house… and saw the conditions in which he lived. I felt the gratitude that both he and his wife had for the gringos that came into the community to help. I watched him in the clinic as he kindly, gently, but persuasively managed the crowds that would build around goody bags and any clothes or shoes that we had for the community. I watched as he decided that the outside of the clinic needed to have banana trees planted. Why? To provide shade for those that came to wait. I watched him wait patiently as gringos stayed for hours just to hang around the wireless internet and watch the same sunset a million times… so that he could make sure he locked up behind us to protect the clinic. I watched him as he sat on the porch with us after work… wanting to know how the day went… talking about how beautiful the views were... thanking us for being there. I wish we had more leaders like Don Quintin in the world.

Yuan – Yuan is a college graduate (from an Ivy League School no less) … who has been accepted to Medical School… but decided that in her post-grad year… she would serve 9 months as an intern for S2S. Here is a girl… who bucked her parental concerns about her safety; bucked the safe and secure route of going from one elite school to another… to voluntarily go into an impoverished country… and live on her own… without the comforts of home… and try to get to know a country… and find a way to help. We come and go from our 1 week trips with a lot of fanfare… this girl is doing this every day. It didn’t take long to see that she had developed an invaluable sense of how things get done in Honduras. Having her on the team opened my eyes as to what could happen when a person was willing to make a true commitment to helping a community. Having her working with you on your part of brigade, made that section run a million times smoother just by her presence.  I can't imagine from where this dedication to her fellow man has come.  I couldn’t imagine making the sacrifices that she has made… at that stage of my life… there is no way, I would have had that level of selflessness and commitment to service… I went into the military around the same time of my life that she is doing this and I can tell you, the difference is immeasurable…  I can tell you that what I did pales in comparision to what she is doing now... And to top it all off… she is considering staying another year… for the sake of continuity of the projects run by S2S. She wants to try and continue the momentum that has started with her work... she wants to help instill some sustainability to the S2S projects.  Her genuine care… and love of the people of Honduras is obvious… Her commitment to learning how to make things run more effectively… her ability to incorporate a new group of gringos coming through every few weeks… I can’t even begin to imagine what she will be capable of once she actually has a medical degree. But I am fairly certain… that she is going to be someone that changes the world. And I am proud to know her. I wish I could have been a fraction of that kind of person at her age… and I hope I can be even a fraction of that kind of person, now.

 The Children –

I think in a community that is impoverished and struggling with so many issues… any bright spot becomes that thing that keeps you going… that thing that keeps you from despairing. The children of Los Pinares… were truly amazing. It broke my heart to see how stunted they were from malnutrition and hard work. But, it also convicted my heart to see how happy they seemed to be with the littlest things. I sat down with two of my favorite kids in the world, Nelson and Elsa, … overwhelmed with guilt at not being able to give them anything on this trip… and I told them… next time I came back, I would bring them book bags and shoes… and they beamed from ear to ear and said, Thank you. And it was so moving to see… that just my words were enough to bring them happiness… that they weren’t jaded… or skeptical… or anything like so many of our kids in the States… they were happy to hear that I said I would bring them book bags and shoes. They didn’t care what kind. They didn't care about that the reality was they may never see me.  They were happy just with the promise of book bags and shoes.

I watched Nelson and Elsa every day as they came back from school… and watched as they just started working. Elsa sweeping the inside of the restaurant… cleaning up dishes… moving fast… working hard… no sign of frustration or distaste on her face. I watched as Nelson stood outside all day… hosing down all of the dust… to keep it from kicking up everytime a truck or bus came through… He did this all day… every day… no complaints… no look of unhappiness or irritation… smiling when I said Hi… chatting with me when I talked to him. This is what keeps a community going… The spirit and hope that lives within the kids.

The Future

So I’ve been back from my trip for a week now. And I’m still trying to fully process everything I’ve seen and experienced. Poverty is a lot different when it has a face and a name… and when it involves someone you actually have come to care about. I have been wrestling with feelings of shame and guilt. I wish I could have done more. I wish I had started sooner in my life. I think about all the ways in which we live so wastefully here in the U.S. I think about everything that we complain about here in the States… and get frustrated at all of the trivial things that seem to create such havoc in our lives. And my list of things that fall into the category of “trivial” has expanded considerably. I feel frustrated with people… I find it hard in some respects to talk to people because I have to fight the urge to tell them how much they have to be thankful for. But it’s true. There is so much to be thankful for here in the U.S. and we don’t even bat an eyelash at how much we complain.

I instantly try to formulate a list of things to bring back. I am trying to talk to more and more people about S2S and Honduras… but I find myself also wanting to encourage more people here to seek out ways to help any community. We live in such opulence and we share so little of it.

I am planning on going to work at a Remote Access Medicine Clinic in Southwest, Virginia this summer for 3 days. I am also planning on trying to go back to Honduras in November for 2 weeks and in February again. I am hoping, I can make this a twice a year trip for me.

I find myself obsessed with books about poverty. I feel like I want to understand why we haven’t been able to make this problem go away. In some ways… I feel like this trip has ignited in me... that part of my heart that had first felt God calling me to medicine… not just to serve the community I am in now… but to find ways to serve the greater community of humanity. It’s been a while since I’ve felt really passionate and excited about doing something in a bigger sense. The past few years as I've finished med school and intern year... I've kind of been on auto-pilot just to get through the hoops I have been supposed to accomplish.  But now... I feel like I have a sense of direction that is not about fulfilling necessary evils.  I feel a sense of real purpose again.  Though, I continue to be racked with a constant sense of guilt and a wish that I could do more… I feel like I found the pair of shoes I was meant to wear for a while... and I like the way they fit.

Sleep

For as long as I can remember, sleep has always been my greatest stress reliever. I know that a lot of people relieve stress with exercise or partying or drinking. On some level, exercise always seemed to add to my stress… primarily because it seemed to always remind me of how out of shape I was. Partying and drinking never really worked for me, because in the quiet moments in between the action, I could physically feel the weight of the stress that I was avoiding.

But sleep… sleep always has taken me to a place where things just seemed to work themselves out… or at the very least… sleep takes the edge off of whatever raw emotions I am dealing with… and when I wake up… I am somehow able to think a lot clearer.

I think a lot of this has to do with the fact that I am such an introvert. I know a lot of people have a hard time accepting that I am introverted, but I really am. I enjoy interacting with people and I enjoy knowing lots of people. But being out and about in public exhausts me… and at the end of the day, I absolutely need time along or with just a few people to recharge myself. When things are stressful… I think the ultimate “alone” time really ends up being sleep.

I’ve also always felt that sleep was when God provided me the most comfort. It sounds silly, but in the way that God talks to us in our dreams… sometimes I feel that in my sleep, God is just there with me… knowing I don’t need to hear Him… I just need to feel comforted by him.

So, I am giving this extended dissertation on my relationship with sleep, because I think that’s what makes my job so tough sometimes. Sleep just doesn’t come easily. It’s a lament that I have made often over the past 6 years or so… often in jest. However, the past few weeks have made this fact especially noteworthy. As I struggled with trying to recover from my patient’s death (see previous blog post), I found that the one thing that has helped me the most was exceptionally hard to attain. And it made it much harder to get myself back to being who I am.

Until… I got sick. Predictably, after everything that has happened the past few weeks, I finally got overwhelmed by one of the many upper respiratory infections I treat 100 times a week. It started last weekend. I started to feel fevers and chills and kind of achey. Then I found myself on call and though my call was mercifully mild, I woke up post-call feeling like I had been hit by a tractor and had no voice. I came home post-call and went to sleep. I did not wake up until the next morning. I then slept through most of that day as well. By Thursday, I was starting to feel significantly better. And I started to try to catch up with my work. That’s when I realized… that sleeping had not only helped me get better from being sick… it had also taken the edge off of a lot of the pain I was feeling. And I also awoke with a lot of clarity.

In the middle of one of these sleep filled days, I somehow woke up to check on lab results that I had ordered on a patient. This patient had had some very odd and troubling symptoms for almost 6 weeks. I originally was very worried that she had a cancer. I checked a ton of stuff initially… which all came back normal. I sent her for studies… all of which confirmed that there were some weird things going on, but none of which gave a definite answer or clue as to what that was. I sent her to some specialists… none of whom really seemed as puzzled or concerned as me. Yet, something nagged me about her. I couldn’t put my diagnostic finger on it, but something was not quite right. So I had ordered another battery of tests… and added a Lyme Test as almost a last minute-why-not-check-this-while-we’re-at-it kind of test. In the middle of my delirious sick state, I somehow remembered that her labs still hadn’t come back yet and I needed to check on them.

When I did… lo and behold… her Lyme test came back positive. I had to read the result multiple times to believe it. It was such an odd presentation of Lyme Disease. She had none of the typical… and all of the atypical symptoms of Lyme Disease. It just was not something that was on my radar as a possible diagnosis. But the most important part of this… is that it was still treatable. So I called her and got her started on treatment right away.

I guess that’s the reality of my job. Medicine is imperfect. I am imperfect. I am going to miss diagnoses. There is no way around it. I could be the smartest doctor in the universe… but it wouldn’t change the fact that there are just some illnesses that simply don’t show themselves in a diagnosable way. Not necessarily rare once in a million illnesses… but even simple, common diagnoses… just because there is a natural variance to things. But in reality… I will probably correctly diagnose a lot more conditions than I will miss.

This all came to me as part of a greater epiphany. I need to get my act together. I think on some level, the fact that I’m a doctor still has been a shock to me. I think about my past and how I got here and it is still hard to believe that I am actually at this point. But it needs to get real for me. I don’t mean in the way I approach my job when I’m at work. I mean in the way I approach my job outside of work. It’s a lot like professional athletes who suddenly realize how much work they need to put into their craft outside of the time they spend on the field or on the court. I realized that the only way I am going to truly do right by my patients is to really put work into my craft. I need to get smarter. I need to get my life in better order. I need to get myself in a better place physically.

This has been a really hard few weeks. I haven't taken an emotional hit like this in a very long time. I’ve gotten a lot of support. I have certainly felt that there were places I could turn. I've had a chance to talk things through more times than I care to count. I've done more soul searching than I ever have before in my life. Finally... I feel that I am coming out of this stretch. But I'm not coming out of it with a sense of relief... I'm coming out of it with a sense of focuse.  I see now the way my life needs to unfold a little more clearly. I see the things that I need to do to take the next step. It took some incredible misery and pain to see all that. But I am excited about the changes I see coming.

And with that… I’m off to sleep.

The Darkness

I’ve had a rough 2 weeks.


It started with just being incredibly busy. I was working in the hospital taking care of our patients that were admitted. Our list of patients at Fairfax is usually 5-7 patients. Our week, it was 12-14. This is a significant difference. And it seemed like every day I was there, a new patient would need to be admitted the same morning I was there. Our patients were also very sick. It was an extremely stressful week.

Then about midway through the week… one of my patients died. It happened very suddenly. It happened very unexpectedly. It happened while I was there. And no matter what we did, we couldn’t bring him back.

….

That’s all I want to say about that day.

….

But, it’s been a pretty steep descent into darkness since then.

….

As a physician, I think none of us is deluded enough to think that we are going to save everyone. Death is a reality of life. And I’m no stranger to it. I’ve seen my share of it. But this was different. It was different in many ways. I didn’t see it coming… on multiple levels… I really didn’t see this coming. I think it was also tough that I was directly involved in his care from beginning to end and that includes being involved in the attempts to bring him back.

….

When something like this happens, I think you start mentally and emotionally killing yourself over and over again. Intellectually, you pore over everything trying to figure out what you missed. Even when you clearly didn’t miss anything and when you clearly didn’t do anything wrong, you feel this burden of unbelievable guilt. It’s not a logical thing. And no matter how much you pore over it and see how things unfolded and know in your head you did nothing wrong… you still feel sick. Everyone involved in the case and everyone who has heard about the case all walked away shocked because they couldn’t see this coming either. And I’ve heard multiple times that this wasn’t my fault. But still… it makes you sick.

….

We all carry insecurities about ourselves… personally… and professionally. Something like this brings all of those out to the forefront… and begins an onslaught of psychological warfare on you.

….

The hardest part is that time doesn’t stop to allow you to recover. You still have to go to work. You still have to take care of patients. You still have to talk and interact with people. There’s nowhere to hide. I was offered the opportunity to take time off... and I wish I could take like a month off to be honest… but I also know myself… and I know that if I took time off… I was not going to be able to come back. So you’re stuck in the open… exposed… and hurting… with nowhere to hide.

….

You also find yourself in this weird catch-22. There’s a lot of outpouring of support. People really want to help. But a) you’re not sure what you need b) you don’t want to really be around people c) but you don’t really want to be alone. I wanted people to know that I was hurting… but I also wanted to kind of be treated like I was normal.

....

I worry about how this is going to affect me in the long run.  Am I going to become the kind of doctor that I hate?  Am I going to be someone that orders everything even when it's not indicated just because I'm afraid that there's something lurking that I can't see coming?  I don't want to be that doctor.  It's like being a parent that never lets their kids out of the house because something bad happened once.  I'm afraid this is going to happen to me. 
….

But as I write this... I know that I am getting better.  It’s taken me a few weeks… but I’m finally starting to do a little better emotionally. I don’t find myself feeling like I’m going to throw up every few minutes. I don’t find myself breaking down emotionally at odd times during the day. I’m functioning better though the day.

….

But I am really exhausted. I can’t seem to get enough sleep. I can’t seem to fight through the fatigue.

….

And I’m still not myself.

….

I don’t feel like joking or laughing. I don’t feel particularly friendly.  I don't know when or if I'm going to be that person again. 

….

I know I’ll get through this. I know that God is with me and always has been with me and always will be with me.

….

But it doesn’t change the fact that I’m hurting… and it’s going to take me some time to come back from this.

Normal

The other day, I did my first endometrial biopsy with a polyp removal. It was a pretty cool procedure. I won’t go into details, because it’s likely to induce severe nausea and sympathy pain. But needless to say, it is not a simple snip and cut. It’s not the craziest procedure in the world, but it is also pretty significant. The procedure didn’t go so smoothly at first… there are a few variables when doing this. My patient was amazing. She handled the whole procedure with incredible grace and dignity. Afterwards, I sat and talked with her and discussed what to expect. She took it all in. Then she asked if she could ask some questions. I was expecting questions related to the procedure and her risk of having some kind of cancer. Instead, she embarrassedly said that she just was never able to ask anyone this, but wondered if she was normal… down there. To hear this initially, sounds like a joke or somehow inappropriate. But it was actually such a pure moment of vulnerability and innocence, that it took my breath away for a moment. It’s such a simple question. Am I normal? I think most of us on some level walk through this life with a sense of this at some point or another. We all just want to have a sense of normal.


I don’t think most people would know it, but for most of my life I have felt like an outsider. Part of this was due to the fact that I was a military brat and had to move so much. I went to 7 different schools growing up and moved 9 different times. I never had that lifetime best friend. I never felt rooted in a community or with a group of people. I had a younger sister growing up, but we were 5 years apart. This was before the time of the internet when staying in touch was made easier by email and facebook. So I was constantly re-establishing myself. I was always the new guy. I was always the guy on the outside trying to find a way in. And on some level, I am grateful for this experience, because I feel like it forced me out of my comfort zone and I have become very good at making conversation and making connections with new people. It’s how I became a “socialized” introvert. But the truth is… no matter how comfortable I got or how many friends I made… I still perpetually felt like I was on the outside being allowed in as a guest. And I don’t think that feeling has ever gone away.

I’ve been in Northern Virginia more years than anywhere else in my life. And this is where I would call home. I know an awful lot of people through all my years here. But I still constantly feel like an outsider. I still have that feeling of wishing I was part of the scenery, not the perpetual guest. I always feel like the friend that people may like and like having around. But not that core friend that is always part of the group. That sounds so high school, I know.

I know that a significant part of this is my own fault. I am constantly in flux. I grew up a military brat and then went on to an adulthood of nomadicism. All of my jobs before school have been stepping stones to medical school. Medical school was transient. Even residency has been transient, because I am temporarily living with my parents and who knows where I will be after graduation. My hours are limited. So even when I am free… I am free for brief stretches… and that often takes a perfect alignment of all of the stars to do something. And after a while… I think people tend to give up on you… because what’s the point? He’s always busy or too tired to do anything. It’s a frustrating cycle. But I still wish people would try harder with me. It’s a selfish, slightly childish statement… but being busy does not equal wanting to be left alone or ignored.

Mother Teresa said, “Being unwanted, unloved, uncared for, forgotten by everybody, I think that is a much greater hunger, a much greater poverty than the person who has nothing to eat.”

It’s something that I think about a lot in the context of my life and my job. I think growing up the way I did… has made me super sensitive to anyone else out there who feels like an outsider or is striving to feel like part of the group… to feel… normal. My patient asking me that question made me realize something about myself as a doctor. It’s really important for me to put people at ease and feel welcome. So when I sit with my patients, it ends up being really important to me that they feel ok about what’s going on with them and feel that they are walking away with a sense of how things are going to evolve. It’s part of why teaching has always been important to me. I carry that feeling of being an outsider all of the time, and I know how much I wish I didn’t. So by extension… I really value being able to take that feeling away for others. Helping others understand their illness, making them feel at ease with their problems, making people feel cared for and listened to… all of that goes a long way towards making a person feel like a “normal” person… making a person feel that they are no longer on the outside looking in. In a lot of ways, I wish my life weren’t like this. I wish I could feel normal. But the truth is, I am also incredibly grateful to have the privilege of knowing that I am making others feel normal… even if I don’t feel normal myself.

Romans 8:28
28 And we know that in all things God works for the good of those who love him, who have been called according to his purpose.

What Exactly Is A Family Medicine Resident?

I get the sense that not everyone knows what it is that I do. I mean, there is the vague sense that, yes… I am a doctor… but I think most people still think I’m some kind of a student or not quite a doctor. But that’s not really accurate.


So I thought I would use this particular update to give people a better idea of what exactly I do.

Once you graduate from medical school you enter into a training program for whatever specialty you decide to go into. How long that training program is depends on your specialty. Most are 3 years. Family medicine is a 3 year program. Your first year of residency is called your intern year. You are working with a training license, and a large hospital or program has agreed to be responsible for what you do. Your intern year is different depending on the specialty. But for most programs, it’s usually the toughest year of the 3. For us, we work approximately 80 hours a week. I say approximately, because this just needs to average out over a 4 week stretch. So you can work 85 hours one week as long another week you work less than 75. I was also on call every 4 days. Being on call involves you do a full day of work in the hospital and then continuing that work into the night and into the next day. It’s 30 straight hours of working. Sometimes you get some sleep. Often you do not. And this “sleep” is a very loose definition of the word. Because you are usually in an uncomfortable bed that has been slept in by hundreds of other people of varying body sizes and shapes and having your pager go off every 2-15 minutes for requests for Tylenol or assorted other remedies by your nursing staff. You get a total of 4 days off in a 4 week stretch. But how those days are distributed does not feel remotely like 4 days.

80 hours is a lot of hours. In the old days, I know that physicians often worked longer than that. And when I was working in the army with Basic Trainees, I worked 100-110 hours a week. I also know that there are other jobs where people routinely work that many hours. I think the only difference is that most people don’t work in jobs in which a small careless error can result in someone dying or being maimed. It’s a little brutal. Congress actually just passed a law that has changed this rule and now interns cannot work more than 60 hours a week, and they can’t work more than 18 hours in a row.

During our intern year, we are completely in-patient. That means I worked in the hospital the entire year. As a family doc, we basically have to know a little bit of everything. So I did Internal Medicine, ICU, CCU, Surgery, OB, Pediatrics, & ER. I actually did very little Family Medicine. It was a really tough and challenging year. I learned a LOT. I thought I had a sense of what being a doctor was going to be like when I was in medical school. Turns out I really had no idea. The more I worked, the more I realized how much more there was to learn. It was also extremely tiring and lonely. It is a wonder I made it through.

Different family medicine programs do this differently. Basically a committee decided that to be a well-trained family medicine doctor, you need to do a certain number of hours doing all of these different things. Different programs will try to integrate these different hours in different ways. Ours puts almost all of the in-patient hours in our first year. For our 2nd and 3rd year of residency, we are almost completely outpatient. This means every day I spend at least half of my day in the office seeing my own patients. What I really like about this is that for 2 years in a row, you are working in the office like a regular family doctor would.

Every so often, we do something a little different from just seeing patients in the office. We will either do an elective somewhere else in a different specialty or we will see patients of the practice who are in the hospital, or we will see newborn babies for the underserved. This is usually limited to a half day and the other half is spent back in the office.  I love the fact that I get to mix things up and do different things, but still continue to see my patients. And make no mistake about it… these are MY patients.

In my 2nd year, we get our license to practice medicine. Not a training one, but an actual one. The Board of Medicine says that as long as you pass your step 3 of your boards, you can request a license to practice medicine. So for our program, we start off our 2nd year of residency, as actual practicing doctors. Initially, in our 2nd year, we have to discuss each of our patients with an attending physician. This is a good thing. It ensures that you are making the right decisions. It gives you a chance to hear different opinions and techniques. It gives you a chance to start developing your own style and technique for managing patients and most cases. After a month or so, you are no longer required to discuss each patient. An attending physician is still there to talk to, but you don’t have to discuss each patient. So since August, I have felt like a practicing family medicine doctor. I see my own patients. They identify me as their doctor.

It’s funny because I have a lot of friends that tell me to "let them know when I’m done" so that they can start to come see me. I think there’s some confusion about my role exactly. I am actually a licensed physician. I have my own license. I am not board certified in family medicine yet. But if I wanted to, I could just work at an urgent care and practice medicine. Most places want someone who has completed a residency training program, but still… I am a practicing physician. And the way our program is set up… I see my own patients.

So what exactly does a Family Medicine doctor do? Pretty much everything. We see newborn babies, little kids, teenagers, young adults, middle age adults, older adults, and geriatric patients. We literally see everyone. We don’t do much in the way of deliveries anymore, due to insurance issues. However, we do Pap smears and Gynecologic Care. We do in-office procedures. We do a little counseling and therapy. We literally… do everything. This obviously… makes the job very hard. You really have to learn to be good at everything.  But I think that it's a big reason why I like being a Family Medicine Doc so much. 

I don’t always talk about how much I love my job. It’s hard to get yourself to admit that most of the time, because you’re usually so tired; and you tend to get very resentful of the fact that your personal life suffers so much. But really… I have to say… I am very happy to have chosen family medicine. Actually, to be more accurate, I guess I’d have to say, I’m very glad that God chose me to be a family doc. It's a job that involves so much variety.  It's a job that involves long-term relationships with your patients.  I love it.

The past month, I have had so much variety, that it has served as constant reminder of why I love this field. For 3 weeks, earlier in the month, I spent my mornings at a Pediatric Clinic for the uninsured/Medicaid patients. Our population there is predominantly Hispanic and lower income… and it's so great to be able to work with them. My office is 99.9% insured and fairly well off. But we get these little pockets of opportunities to work with the uninsured. Once a month, we go to a free clinic where we work with the uninsured and every so often, we have pockets of working with this pediatric clinic. I love working with the underserved populations. I don’t know if I’d want to make it all I did, because I love seeing my patients; but getting the chance to work with uninsured patients every so often really makes me appreciate healthcare and the things we get to do for people.

I’ve also picked up a couple of newborn babies in my own practice. Many of the babies are with first time parents. Working with first time parents is extremely rewarding. I love being able to talk to them about all the ways that their baby is weird to them, but normal for their age. I love being able to prepare them for changes to their baby. It’s such a fun thing to be able to do.

I’ve also had the chance to do a ton of procedures lately. I put in earrings in a baby for the first time. It’s a little scary, but oh so cool to do a procedure that instantly results in such a beautiful thing. I’ve cut out some cysts. I’ve shaved off some simple moles. I’ve punched some moles out. I’ve put in some stitches. I’ve burned off some skin lesions. I freeze stuff off all the time. Procedures are probably one of my favorite parts of family medicine.

I’ve had some of my patients with depression/anxiety come back to see me and tell me they are doing much better. I’ve had some people come to me because I took care of their family members. I’ve taken care of some patients who had been bouncing around from doctor to doctor and cleaned up their care plan to good results. I’ve been managing a TON of sinus infections without antibiotics. I’ve been helping people work out insurance issues. I’ve talked to some troubled teens. I’ve talked to some overwhelmed parents. I’ve done some worrisome paps. I’ve also counseled some teens & young adults on good gynecologic care and STD risks.  I really get to see the whole breadth of health care, but in the context of continued relationships.  It's such satisfying work.

It's not all roses though.  I still have to take care of some difficult patients.  This usually doesn't mean medically difficult.  It's usually in reference to their personalities.  We live in a very entitled area, where people think they know better than their doctors sometimes.  I also am on call every 5-6 days.  When I am on call, I have to see patients in our immediate care clinic in the late afternoon into evening.  At night, I have a call phone in which I have to answer any calls from patients, from any of several nursing homes that we cover, and for any of our patients in the hospital.  This can be a few calls or it can be a non-stop process.  I also have to admit any patients that are coming through Fairfax or Fair Oaks Hospitals.  So if any patients from either our practice or any of the 10 total branches needs to be admitted to one of those hospitals, I have to drive in and examine them and do all the paperwork to get them properly evaluated and treated.  This means that at any one time I may get multiple people coming in to Fairfax and Fair Oaks hospital at once.  This has happened.  This is stressful.  It's a tough process.  When no one needs to be admitted, I can just relax at home.  But it is very rarely that easy.  The next morning, I still have to come into work and see patients. 

And my work isn't just limited to what I do in the office.  For every patient I see, I have to document the entire visit.  What they said, what I saw, what we decided to do.  It's an important, but VERY time-consuming process.  And I don't have enough time to document everything as I see them.  So I have to bring some of that work with me.  I end up working 55-60 physical hours in the office.  And a total of 70-80 hours a week outside of all of that.  Work can end up being all-consuming.
So this is one thing I really hate about things.  I hate being on call.  I hate bringing work home.  I hate not having enough of a personal life and always feeling tired.  I hate the fact that I can't seem to get my personal life and my homespace in order the way I'd like, because I either have too much work to do when I get home or just want to complely veg out.  So there is a lot that I hate about the nature of my life right now. 

However... the truth of the matter is... I really love my job. I am so glad I get to contribute to people’s lives in such a meaningful way. I love the feeling that I am able to be part of people's story.  I love being able to solve problems.  I love bringing comfort to people.  It really does make it all worthwhile.  I want to try and remember that more often and not get lost in my fatigue and weariness.

I'm Back to the Show

I haven’t updated my blog in almost a year and a half. I have thought about posting so many times, but it’s been difficult to do for a number of reasons.

1) Time – when you only have 24-48 hours of total off time a week there’s not a lot of wiggle room for chill time.

2) Dominoes – the longer you go without posting, the more you feel like you need to catch people up with and so the idea of an update seems more and more insurmountable.

3) The Law – 90% of my life now involves patient care. Federal laws prohibit discussing details of patients unless it is directly related to their care. So it gets really difficult to talk a lot about my days without revealing information that will get me fined or put in the pokey. It’s doable. It just requires a LOT of careful concentration and thought, which causes the most difficulty. See #2.

4) Whine & Cheese – Most of the time you usually feel like you need to unload emotions, it’s in the setting of significant emotional stress or significant emotional uplifting. So your posts become awful self-indulgent whine-fests or disgusting cheese-filled outpours that make you nauseous months later.

But recently, I had a bad week/few days of work and I went looking through my old blog and found a post that really made me smile, because it took me back to the end of my 3rd year of medical school and was filled with a sense of excitement at finding a sense of where the next few years of my life could potentially be. And I loved that I could see myself filled with that kind of excitement.

So I got convicted. And I’ve decided to get back to it. And I figure I’ll just have to put something up as often as I can.

Happy Birthday to Eleanor Kang and Deborah Choe! I love you both!

Costa Rica Days 3, 4 &5

Sunday, May 31, 2009 - Day 3

I left San Jose to go to Dominical. The roads here are kind of miserable. So traveling the country takes a lot longer than it should. There were 2 sisters, Lesley & Jessica who were traveling with me to Dominical. We got on a bus that took us to San Isidro, where we would be picked up by a driver to take us the rest of the way to Dominical. It´s a 3 hour trip to San Isidro and a 45 minute trip to Dominical. The bus was nice. But there are little things that made the trip uncomfortable. I had a window seat and the guy in front of me leaned back. The corners of the armrest or the chairs were kind of painful to lean on. And the woman next to me was a little Costa Rican woman who looked like a monchichi doll... who kept staring at me as I sat there. I took a lot of pictures... but the ride was so bumpy I tried to sleep... We stopped at a rest station on the way and I had a little snack: ¨Papas¨ which are little empanadas stuffed with potatoes. It wasn´t a lot... but it was tasty. I accidently tried to go to the ladies room, because the signs said damas & caballeros, which is ladies & gentleman. I didn´t recognize those names at all. A nice costa rican woman corrected me gently. Hahahaha...

When we got to San Isidro, it got chaotic. Everyone wanted to be our taxi. It was hard to kind of avoid all the drivers that were asking us if we needed a driver. We finally met our actual driver, Alvarro. Alvarro was good peoples. He didn´t speak much English at all, but we bonded. We had to drive across the mountains to get to the beach. The views were amazing. It was really cool to feel the climate change as we came out of a landlocked city, into the mountains, and down into the seaside town. As we got into Dominical, all sense of civilization started to drop of. And the tiny town began to appear. It was a dirt road with all these tiny little shops and stores that clearly catered to surfers and beachgoers. There are open air restaurants everywhere with surfboard rental shops everywhere you look. There are huge palm and coconut trees and fruit markets everywhere you look. I got dropped off at my cabina, where I waited for the landlord, a guy named Billy Bob. That´s right... Billy Bob. Before I got to Dominical, I was planning for the worst. I knew I would be near the beach, but I didn´t know what the facilities would be like. They said, I might have a roommate & they had said that if I wanted AC it would cost $50 more a week. I had decided in my head, that I was going to try to rough it and go without AC. So I was a little nervous about what the cabinas would be like. When I got there, I noticed 2 things. 1) I was really really really close to the beach... as in a 10 second walk... and 2)the building I was staying in was quite decent. When Billy Bob showed up and took me to my place, I was really pleasantly surprised. It was small... but the bed was full-sized... I had no roommates... and it was quite clean with a good ceiling fan.

I settled in, got changed into comfortable clothes... and headed to the beach. The ocean in Dominical is pretty impressive. It´s a brown sand beach with an incredible open, barren view. The surf is really impressive. Lots of small and medium waves with very large waves further out. There really is no other beach that I´ve ever seen that looks similiar. I strolled along the beach and into the town, where I made my first and most important purchase in Dominical... insect repellent. The mosquitos & flying bugs in this are quite fierce. I got this cool all natural costa rican spray called green screen. It smelled good and made me feel good about buying green and buying local. I was pretty hungry, so I went to the most unpolished, local looking place I could find. They call little eateries, ¨Sodas¨here. I went to Soda Nanyoa. I got a little snack instead of a whole meal because it was kind of late. It was called a Gallo con carne and was basically stewed beef with 2 small tortillas and a tiny salad. I also had a pineapple smoothie. The whole thing came out to $4.50. On the way out, I noticed they had a fruteria (fruit market) and I saw that they had one of the items on my ¨to eat¨list... a coconut. I introduced myself to, Juan, the owner of the fruterria, and got a coconut for the grand total of $1. Juan put a straw in it for me and I was on my way. Coconut milk is interesting. It´s not that sweet. It´s not that thick. It´s not that cold or cool. But it´s... very refreshing... It was really very good. I felt cooled down and happy after I was done. It had no lingering after taste at all. I have been told that it can be a laxative. It did not have that effect on me. I then walked over to the school to officially check in. I met up with the sisters again and also met a couple named Elliot and Sheri. We got to talking and it turns out that Elliot just graduated from Med School as well and was going into Peds. Even cooler, it turns out he´s friends with one of the residents that I´m friends with from Fairfax Family Practice. It was pretty cool... but I guess I shouldn´t be surprised to run into 2 degrees of separation anymore... even when it happens a world apart. We had dinner that night at a Thai restaurant and it was quite good. I slept very happy.

Monday, June 1, 2009 - Day 4

I slept pretty well despite no AC. The ceiling fan really helped... as did the cold showers before I slept. God is good. I walked to the school taking the scenic route along the beach. It´s hard to put into words how beautiful this town is. The sound of roaring ocean is something I will not soon forget. I did not want to stay with a host family in dominical for 2 reasons: 1) I kind of felt like I wanted a little break/vacation at the beach and I knew the cabinas offered that. 2) I wanted a week of spanish under my belt before I stayed with a family. So since I wasn´t staying with a family, they had breakfast for me at the school. I met my pseudo-Costa Rican mom, Anais. She gave me a plate of Gallo Pinto and a fried egg with some great coffee. I really didn´t think I would be able to eat rice and beans every day, but I have to say, I think it´s great. After breakfast, we took placement tests... of course I was placed in low beginner. Our class had 8 people, because we were all beginners and not enough teachers. Our teacher was an adorable woman named Senia. She´s a 24 yo single mom who speaks no english. She was great. I found that I was able to understand a lot more because of 2 years of Italian and having studied 4 different languages. Speaking is a whole other story. It was really hard to keep the Spanish straight from the Italian. Our classes go from 9-1:30. We have 15 minute breaks where they give us snacks. I love the cookies here... and of course... the fruit. I could live off of pineapple alone. We had orientation afterward followed by some errands. It´s really a pretty town. There are a good amount of Americans and foreigners here... mostly to surf. There aren´t a LOT of shops and only a handful of restaurants. It was a pretty hot day, so we decided to hit the beach! The surf is very intense and the beaches are basically empty. I had so much fun just getting rocked by the waves. I went to dinner that night with Sheri and Elliot to the local sushi place... it was... less than great... but oh well... We ran into the sisters on our way out and decided to go get dessert at this place near the cabinas called Hotel Domilocos. We ran into another couple from the school, David and Alyssa. I decided to get Banana Flambe since I love Bananas Fosters. The presentation was amazing... and it tasted great. I´ll try to post the video later. Another great day in Costa Rica... tomorrow... surfing.

Tuesday, June 2, 2009 - Day 5

I love walking to school. It´s so incredibly beautiful. Anais made me an omelet with brocolli. She´s really great. She has 2 girls in their teens and a 2 year old named Franklin. Her and her husband both work with the school. She really treats me like her son. My teacher asked me if I was comfortable in the class. She thought maybe I might want to move to a more advanced class. I was flattered... but I knew that I needed the basics and that I was only good with the bits and pieces. I needed structure to bring it all together. We now had 6 in the class, because 2 of the students had studied more spanish. I have to say... it is fun to be learning a language again. I really enjoy it. Because I am able to understand Spanish well, I am the official class translator. It´s a good job, because it´s forcing me to be on my toes.

I had my first surf lesson in the afternoon, so I needed to eat quick. I was supposed to meet the instructor in a restaurant called Tortilla Flats, so we decided to just eat there. Tortilla Flats is a restaurant right on the beach itself. It is clearly a favorite with the surfers. It´s owned by an American and there are American waitresses there that don´t speak a lick of spanish. I had a Mahi sub... which was delicious... but it´s kind of sad to see so many American owned rather than Costa Rican owned places. We met Ronny... our surf instructor. Ronny is from Dominical... and has been surfing since he was 4. We had to go get the boards... but for some reason... I thought the boards would be nearby... so I left my flip flops behind. Walking across rocks to get to the surfstore was NOT fun... We practiced getting on the board a bit before we went out... and then we got into the water. I almost got up on my first run... it was definitely tricky... but I got better. It was pretty amazing to be sitting there and realizing that I was surfing in Costa Rica. It started to rain and it just added to the experience. Something about surfing in the rain... on an isolated beach in Costa Rica... is just too amazing for words. We surfed for 2 hours. I got 5 really good runs... and a handful of so so runs... it´s very tiring... but the most important thing... is that my last run... was a good one.

After we washed up, we went to a placed called Marakatu. It was a local vegetarian restaurant. I got the Mahi Mahi special with a pineapple smoothie (sense a pattern here?). It was so delicious. For dessert, I had a brownie with ice cream. Afterwards, we went to Coco´s. Coco´s is a local Tico restaurant and bar. It´s one of the first restaurants ever opened in Dominical. We were having our welcome drink with the director. We had Fresca... which is almost the same as Fresca in the States... except it´s not sugar free. They added Cacique... a local liquor made from sugar cane. I just had Fresca. Afterwards, we did a little Karaoke. It was kind of ugly at times... I sang a few songs... Britney Spears, Feliz Navidad, and Girls Just Want to Have Fun. It was a late night for me. Usually I´ve been sleeping at 9-9:30. I went to bed at 11. I was BEAT.

Tomorrow... I start medical spanish... and I go ziplining!