An incredibly cool physical exam finding!

I really wish I had access to uptodate or other internet resources that I use at home! I had a patient come in with one of the most obviously abnormal findings I've ever ever seen! Not to sound totally creepy but she had the absolutely largest most inappropriate sized breasts EVER. As in she was a super small girl who had breasts that were EACH probably the size of two watermelons, as in a minimum weight of 20lbs. And to answer Meredith's question- waaaay larger than any implants possible. It was insane. I'm sure she has some hormonal problem but I have never ever heard about something like this! Friends from home, please email me if you find any links on uptodate about really huge breasts! I don't want to dare risking googling "really large breasts". ;)

Ahora tu eres dominicana!

Labor and delivery can be crazy in any country. At least from my perspective, the craziness here in the DR is a bit different than what I am used to. At home, when there are sick patients or stressful situations you can tell because everyone is revved up. Here, no matter how crazy things seem to be from my perspective, residents are still laughing, making jokes, planning the weekend, etc. Sometimes it's hard for me to realize that there is a critically ill patient because no one seems to be acting any differently- I guess they must all be so used to seeing this acuity of illness. I'm impressed with how darn calm they all are and how much fun they make work to be!

Today I worked again on L&D. Today, I ended up repairing at least 6 episiotomies (I lost count!). For non OBs, this can be tricky because there are often many different layers of suturing that have to be done depending on how far the episiotomy extended. I feel like I'm getting pretty good at it! I even have fun chatting with the patients (of course in Spanish) during it. I'm excited that I think my surgical skills are getting more confident but I'm also really proud that I'm able to start being more like the clinician I feel I am at home- consoling patients, chatting away, etc. After some awesome encouragement from Nina, I realized that I could still be the clinician I wanted to be even though it's in another language/culture and even though no one else I was working with was being supportive to these patients. It felt great to hold a laboring woman's hand, acknowledge her suffering, and tell her to relax nicely. I felt like the OBGYN I like to think I will become one day. So thanks Nina!!

Sometimes the labor room is especially busy and there isn't any room for more women to deliver. I saw a resident deliver two separate babies on a regular hospital bed today in the laboring room. I felt so bad for these women- they were laying in a pool of their own blood, stool, and amniotic fluid and were covered in it! The other women in the laboring room (about 20 or so) were strangely respectful- they all kind of stopped screaming during these deliveries and looked away to give these women some amount of respect for what she just went through. These are some super tough women that I'm working with!!

A crazy thing happened today- the power went out in the hospital twice! One time, while I was delivering a baby! Since the delivery rooms have no windows it was completely dark. No one around me seemed to care that it was dark so I waited a few seconds and then just tried to continue working. Luckily, the lights came back on before I completed the delivery of the baby's shoulders! Power outages still happen here in the DR often- not as much as in the past- but it probably still happens a few times a week. Looking back at the power outage today, it's really cool how I didn't even think to get stressed about it being completely dark- I just kind of kept working. I doubt that I will ever have to deliver a baby in the dark back home in residency, but it definitely is something that has boosted the confidence I have in my clinical skills!

One of my favorite things that happened today is related to the title of this entry which translates to "now you are a Dominican!" I forgot to mention earlier that since deliveries happen so fast and supplies are minimal, the only protection I have from the patient and her body fluids are my glasses (thanks Mom!), scrubs, and a single layer of gloves. For anyone who has seen a delivery before, you can recognize how difficult it is to deliver an infant and only get your gloves dirty. Anyway, after getting splashed today by various body fluids, I picked up a habit that I had seen the other residents doing- I now tie large black garbage bags around my waste so that when I do get splashed my scrubs are less likely to get drenched. I spent the rest of the day walking around in scrubs and garbage bags. One of the attendings saw me and told me that I finally was becoming a Dominican. She then encouraged me to show off my new attire so I did a nice catwalk down the laboring room and everyone stopped to applaud and cheer me on. It was super fun but I guess a little strange if you weren't there! Who would have known that something as gross as getting soaked by body fluids would turn into something that helps me become more accepted by colleagues?! :) That said, I really look forward to practicing back home where I don't really have to worry about getting covered in someone's body fluids.

An adventrous weekend!

I had an AWESOME time this weekend! I woke up early on Saturday and took a bus to the northern coast of the DR called Samana. Of course, the bus had to break down along the way. And of course, there was no cell phone reception as we were driving through the hilly jungle on a dirt road! I finally got in- 4 hrs late- to Samana and decided not to have too many more adventures that day. Instead, I headed to my hotel in the sleepy fishing village of Las Galeras using the public transportation (called a gua-gua, it's a really small minivan that they cram about 10-15 people in, and sometimes live chickens!). Although the trip was exhausting and at times stressful everything was totally worth it once I got into Las Galeras. My hotel was heavenly- huge, safe, clean, warm water in the showers, overlooking the ocean, with a balcony... it would be a great hotel room in the US but it was absolutely INCREDIBLE in DR terms and in my mind after living here!

The town of Las Galeras was incredible! It's a one-road fishing town where everyone is friendly and no one is ever in a rush to do anything. I strolled on down to the most amazing beach I've ever seen and took a glorious swim in the warm crystal blue ocean. When I got out, a man walked towards me and asked me if I would like him to cut down a pineapple or coconut from one of the tress on the beach for a snack- don't mind if he does! I spent the rest of the afternoon just relaxing, taking tons of pictures, feeling so darn lucky to be working in a country this beautiful when you get away from the city! I can't wait to show you all the pictures- not a bad day of work!!

Since it's a fishing town, the food was all incredible and heavenly and inexpensive. I spent the evening talking to people who walked by my table under the palm trees, listening to music locals were playing, and sipping fresh juice. It was pretty darn awesome. I can't say it enough- this place was paradise. I could easily see myself never ever leaving here. The biggest problem I had here was overcoming my inertia and strong desire to just never do anything ever again.

The next morning, I went whale watching!!! It was awesome!! I got to see humpback whales several times- incredible!!!!! Definitely a once in a lifetime experience. Every year humpback whales travel to this area. My tour guide was the woman who first realized that humpback whales migrated to Samana between January and February. She came to work as a scuba instructor, found a humpback whale on a dive, and never left; now it's 25 years later and she doesn't miss the snow in the US at all! How amazing is it that I got to watch the whales with such a legend?! I took tons of pictures and can't wait to share them with you! In the meantime, check out her website for more info about the amazing trip!

http://www.whalesamana.com/home.html
http://dr1.com/travel/special/whales.shtml

I also did some touristy things in the villages I spent time in this weekend. I bought an awesome painting from a local artist. I also bought David some hand-rolled Dominican cigars to share with the guys on our wedding day! :)

As I've learned so many times here in the DR, Dominican time is a bit different and it's best not to plan your day out too well. My 4-5 hr whale watching trip was 7.5 hrs and despite frequent reassurance not to worry about time from the locals, I was less than 30 seconds from missing the last bus back to the capital! I came back to the hostel super excited. My first weekend exploring the country on my own was a huge success! I had an amazing time and better yet, I had an adventure that gave me tons of confidence with exploring the country and speaking conversational Dominican (which is very different than conversational Spanish!).

Perhaps the best part of my weekend was a phone call I got from David. As our Valentine's day present, he bought tickets to visit me in the DR!!!!!!!!!!!!!!!!!!!!!!!!!!!!! I have had trouble sleeping since I found out the great news- I just can't wait to show him off and show him the DR! I'm excited for all the fun trips we will have! My biggest challenge is going to be getting David to be patient with Dominican time here- he's even more of an itinerary type A personality than me! I get to see David next week! Yay yay yay!!!

A different world

Today was my first day working on labor & delivery. It was pretty darn insane. The laboring room is a large shared room where about 15-25 women wait to be completely ready to start pushing and give birth. While they wait, most lay completely naked, legs spread open, screaming in pain as others walk by ignoring them. Everyone at the hospital seems very used to the fact that women are screaming all the time and ignore it, some even laugh at a particularly vocal patient. At one point today, a woman was screaming so much so I went over to her to check to see if she was complete (ready to deliver). One of the residents stopped me and said, "Don't worry. Ignore her. She will learn we don't give preferential treatment for being loud and she will quiet down." I felt so awful that I had to ignore this woman who was shrieking in pain. It felt so wrong to let her deal with the pain by herself. In case I forgot to mention earlier, patients are not allowed to have visitors so they go through all of labor, delivery, and postpartum alone; they can't see anyone outside the hospital and no one can see their baby until they leave.

Another fantastic quote from today... a patient was just admitted from the emergency department in labor. It was her first time giving birth. She didn't want to lay down on her hospital plastic mattress because there were no sheets on it and it was dirty from someone else's blood. When she told the resident who tried to get her to lay down on the mattress so he could examine her, he laughed and said, "This is a public hospital stupid. We don't give everyone bed sheets. Lay down."

The lower level residents deliver the babies. The upper level residents wear white and therefore usually only stop by if needed. For the most part, we are on our own in the delivery. The goal of the residents in the delivery is to get the baby out as quickly as possible. If the woman is scared or isn't pushing "enough" , everyone in the room laughs at the patient and tells her to "stop dreaming and grow up." Some of the residents smack the patient on the forehead if they think she needs a "wakeup call" and needs to push more. If you are taking too long in the delivery, the senior resident comes by and says "This is taking too long. Cut her right now" (cut means cutting an episiotomy to make more room for the baby to come out). During one of my deliveries today, the baby was making good progress and was coming out just fine. This patient was young and this was her first delivery so she was scared and needed some coaching; she had only tried pushing 2 or 3 times. When the senior resident said the patient was taking too long, he told me to cut her. I hesitated, not just because I didn't have experience with episiotomies or not just because I thought that she didn't need to get cut (even though I don't think she did), but also because this woman did not receive any pain killers or analgesia of any kind before he wanted me to cut her. He pushed me aside, took the scissors and cut about 2 inches into this woman's perineum. Despite seeing many natural child births back home and all the births I see here are without analgesia so I had heard my share of screaming and pain, I had to look away from this patient when she started screaming. I have never ever in my life heard that kind of a scream. The resident gave her a large episiotomy and pulled the baby out without any consideration of pain relief, not even local analgesia. He walked away and the woman was left there alone, bleeding, still shocked by what had just occurred. She laid there alone, naked, with her legs still in the stirrups, bleeding because the resident had to go to another delivery and didn't have the time to stitch up her wound for another ten minutes. When I finished with the patient, I walked away and realized that my surgical mask was wet and that at some point during this episode I must have cried.

As I mentioned before, physicians here do not use ultrasound monitoring to hear the fetal heart beat; instead, they listen using their stethoscope. This is a technique that I am still working on. One of the residents teased me that I didn't know how to do anything here and asked how we could possibly monitor patients differently in the US. As I looked around the crowded room full of women in labor, windows open, with flies accumulating on the patients that were too exhausted to scurry them away... I didn't know where to begin describing the difference. I started telling this resident that where I trained, every patient was constantly monitored for contractions and fetal heart tones. I didn't even bother to describe that every patient had a private room or the other luxuries patients have in the US. I could tell that talking about constant ultarasound monitors, let alone central stations with computer access to these monitors was an entirely different world. I'm learning tons from my experience, some are positive experiences and some are negative experiences but all are great opportunities for learning. That said, I know that I will come away from my month here with an extreme gratitude for the medicine I have a privilege to practice back at home.

A great week

I finished off my first week at work. Today was a really awesome day. I felt like I knew what I was doing, felt pretty confident with my Spanish in the hospital and outside of it. Today everyone was celebrating the upcoming Valentine's Day. For about two hours, everyone kindof stopped working to enjoy food and spending time together at work. It seems corny but it was really cool! One of the attendings brought his guitar and everyone just sang, danced, and had fun! Everyone was having so much fun in our party in the emergency room that they decided to move the party to the labor floor (the big room with tons of hospital beds and naked pregnant women waiting for the doctor to be ready to deliver their baby). Although everyone in the party was having a good time, but I have to admit it was really a bit weird to be dancing, singing, laughing in a room where women were screaming in pain as they had natural child births! That said, it was really nice to feel included and see how different the dynamics between co-workers can be in a hospital at a different country.

I have a really good friend at the hospital who is a first year resident. She is a native Haitian, who moved here to the DR for medical school. Her husband is in the US trying to take the US medical exams and get into medicine in the US. And she is super patient and kind with my Spanish. We had tons of fun chatting today; it was only once I got home that I realized that talking to her was pretty effortless even though it was in Spanish! This must mean progress!!

Tomorrow morning I am leaving for an adventure! I am going to Samana, a peninsula north of the capital. The region is known for some of the world's best beaches, amazing nature scenes, and whale watching! I'm excited to be venturing out of the city! I can't wait to tell you all about it!

Rounds

"Rounds" are a way for a team of physicians to review patients and the day at hand. There are many different ways of "rounding" , some more formal than others. Most of the time in the US we have walking rounds where whoever is taking care of the patient updates the team with how the patient has been doing over the past 24 hrs. In general rounds are a way to exchange information as well as to learn from the patients. Rounds usually have a bit of hierarchy involved- the attendings are everyone's boss, senior ranking residents are responsible for the team, residents are responsible for their patients, medical students are responsible for staying alive. :)

Here in the DR, rounds are very structured and formal. Every morning, the residents that are post-call present to the entire hospital in a conference room. It took me awhile to realize this but everyone sits according to rank. The pre-interns sit in the back and wear beige scrubs, the interns are the next up in green scrubs, the upper level residents wear all white, and the attendings sit in the front row. The first few days, I sat in the back because I didn't want to get in anyone's way and because I feel pretty lowly in the scale of my medical training in general, let alone in Spanish. As a guest visitor, however, I get to skip up a few ranks and now sit in the second row from the front. It's pretty neat although the attendings see me more and try to engage me in debates for "my professional opinion" about the debate at hand from my experiences in the US and of course "what Williams says." Williams is considered a Bible for Obstetrics and it is really worshiped here. FYI Williams is written at UT Southwestern, one of our top programs we ranked!

Rounds at this hospital in the DR starts off with a prayer. One of the senior residents leads the prayer thanking God for the honor to serve this population, and prays for the safety of the residents and the patients; then, everyone joins in and recites the Our Father. One of the senior residents then lists off all the deliveries, complications, births, deaths, surgeries, procedures, number of blood units available today, etc. Next, the resident presents patients in the past 24 hrs that had complications or were particularly unique.

The volume here is like nothing I've ever heard about- at least 60 deliveries/day. One resident told me that this morning she delivered 36 babies this morning. WHAT?!! I have no idea what to expect next week when I work labor & delivery but have a feeling it will be challenging!

The severity of cases discussed here are equally insane. Everyday we talk about things that I've been told I would probably never see in my career- here it happens every day. It's really exciting to come home and read about things that I've never even thought could happen. I'm learning so much!

An awesome 24 hrs

Last night I met really neat people staying at my hostel. They are ecology graduate students that do field work throughout the DR. They spend months at a time exploring the huge uninhabited areas of the DR- they even travel with a donkey! I had such a blast learning about what they do- it's totally different job than anyone I've ever met. I've been here less than a week and have already met so many incredible people!

Since there were some guys in the group, I ventured out of my hostel after dark. We went to an authentic Dominican restaurant. The food was awesome and the company was wonderful. As lame as it sounds, making new friends every few days is really awesome. The restaurant had live music and dancing. I loved watching Dominicans dance- they are incredible! I even got to dance a bit. It was a blast!! Being here in the DR makes me feel so alive sometimes- the music, the people, gosh it is just awesome!

I went to work with a level of excitement- today would be better because I would be better prepared. I understood much more of the morning conference. The acuity of illness seen in this hospital is insane. As a quick example for any medical readers, a woman came to the ED pregnant with pre-eclampsia which turned out to be thyrotoxicosis which rapidly lead to congestive heart failure, C-section, ICU admission, and sadly death... all this happened within a matter of a few quick hours.

I felt brave today in the ED. I walked into the crowded waiting room and did my own triaging. I saw some really awesome patients. I understood them (for the most part) and they understood me (for the most part). I presented my patients in Spanish using all the right words I had written out the night before and admitted several to the hospital. All of this would be pretty easy standard stuff at home but I was just so darn proud that I could stay afloat today. As a result of the mini personal victories, the number of patients and the acuity of illness seemed less overwhelming.

I have a HUGE amount of respect and love for my co-workers in the hospital. They are incredibly patient and kind with me. More, absolutely everyone I have worked with has unheard of phenomenal clinical skills. I can't say this enough- they are AWESOME whether they are medical students, interns, or residents. For every pregnant patient, they use their stethoscopes to measure the fetal heart tones. How insanely awesome is that?! Clearly, it's a technique I'm still learning since back home I was pretty spoiled with using Doppler ultrasound on everyone (and used to be super proud of being able to hear the heartbeat easily).

So the past 24 hrs has been awesome. I'm still sweating tons, learning tons, and adjusting but today is the first time I'm excited to say I feel like I'm making progress. :)

No other words- insane.

Today was my first day working in the emergency department at the largest (and public!) hospital in the Caribbean. Every morning starts out with a morbidity and mortality reviewing what happened the day before. This morning, over 60 babies were delivered. The cases discussed were probably the most insane things I've ever heard about- a baby weighing 7500 g at birth, insane infections of the uterus. We just don't ever see these kinds of things in the US.

Everyone in the hospital is very friendly and welcoming. My Spanish is getting better- at least for today! I spent a lot of time with the residents today, learning how to describe patients in Spanish when presenting them to attendings. Although I have plenty of practice speaking to patients in Spanish, learning the medical lingo for describing them to other physicians was tons of new vocab. It was really tough!

The ED in the hospital is a large room with lots of "stalls" with patient beds. Women are told to enter their stall and take off their clothes; there they lay completely naked, alone, exposed on tables covered in garbage bags to keep them clean. The women that are allowed into the ED out of the small crowded waiting room of about 50 women are triaged, which means only the ones who are suffering most are seen. I've seen plenty of women who I thought were suffering in the US but I NEVER ever witness the agony of each patient who came to the hospital. These women literally come in because they are dying. I knew to expect a much different type of experience this month, but nothing can prepare you for the types of things I saw today.

Although I only worked 7am-12pm, it was the hardest day of my life. I walked out feeling sick, everything was a blur. As I pushed past the 50 or so people waiting for space to open up in the lobby to enter, a woman saw me and tried to give me her newborn baby to take with me. I walked home feeling completely exhausted and numb. At home, I couldn't do anything but lay down and try to sleep. I forced myself to wake up and eat lunch. Luckily, my hostel mother saw the exhaustion in my first day and gave me a cup of amazing Dominican coffee. I felt better soon and was motivated to read up on all the ill patients I saw today. Tomorrow will be another challenging day for sure, but I look forward to the challenges ahead of me.

Staying afloat

Today was my first day of work but it was more of an orientation day than work. I spent most of the morning waiting to figure out who I will be working with. As I tried to chat with peers, I was scared to learn just how different certain dialects of Spanish can be and how difficult it can be for me to understand them. Many of the people I met used slang and spoke rapidly… all which made me feel really uneasy about signing up to work here a month! I guess my biggest worry was that everyone here would think I was stupid or would ignore me. I’m used to feeling like a good student and was suddenly totally overwhelmed with the thought that I may be the dumbest person that they work with all year because my Spanish isn’t up to par and because I’m not used to their way of doing things.

Luckily, I met a really nice residency coordinator who answered all of my questions nicely even if I had to ask her to repeat things a few times so I could understand her. I was relieved to find out that nothing was lost in translation and that the residency coordinator here understands that I am just a medical student and that I don’t start my residency until the summer. Phew! She was very friendly and encouraged me to make the experience my own. I’m only required to be at the hospital from 7am until noon! Of course, they said I could stay longer and work as much as I want, but that would be up to me. It felt like a relief that they don’t seem to expect much out of me. I’m worried that I will disappoint everyone! This week I will be working in the emergency department of the women’s hospital. Next week I will be working the labor and delivery floor. After that the post-partum and then “we will see”.

I got a tour of the hospital today. Since it is so warm outside always, most of the hospital has tons of windows for “natural air conditioning”. The hospital is divided into large open wards where patients have no privacy and at times are sharing beds. Women sit bed next to bed naked, moaning, exposed. My first reaction was to look away in the hopes of providing decency. In the laboring room, women lay in their beds, waiting for their turn to deliver. Perhaps most shocking was the delivery rooms where women were on small tables completely naked but covered in blood, being operated on in a large common room. It was definitely something that I’ve never seen before.

I'm sure that I will have more stories to tell later in the week once I start working more. In the meantime, I'm trying not to be too hard on myself. There are times when I feel great being here and there are times when I'm not going to lie- it's a struggle. I started feeling really overwhelmed and tired at the end of the day today; I was frustrated with my Spanish and still struggling to run in the weather. I wanted to use the internet and feel like myself again but the internet went out. I felt so alone and wasn't sure how things were going to turn out. Luckily, as I went to the kitchen to get a snack, I met wonderful people my age and spent the rest of the night with new friends. Even more, I was super excited to find out the internet returned. Thank goodness!! So the day started out exciting, then I got frustrated with my running and my language skills, but ended well thanks to David's phone call, new friends, and internet access. I'm glad to report that I think that qualifies as staying afloat. :)

Hasta la proxima...

Tourist day!

I started off the day with a nice run along the ocean. I hate to complain because the scenery and sunshine was wonderful, but I had a hard time getting used to the heat and running without music (for safety reasons). I'm hoping tomorrow morning will be a better run. :) Even my running, something that has become a huge part of my routine and how I like to define who I have become, has to adapt to being abroad. Google maps pedometer, the way I usually track my distance for running, doesn't work in Santo Domingo so I'm just estimating how far I go with my watch. My Type A personality has lots of adapting to do!

I spent the rest of the day walking around the capital, exploring the historic colonial zone of Santo Domingo. The island of Hispanola was one of the places that Christopher Columbus landed and many of the original architecture from that era still exists in the downtown.

I took lots of pictures and hope to describe all the neat places I visited once I upload them on my computer. I haven't found my USB cable to upload pics yet because I haven't unpacked yet. I haven't unpacked yet because my hostel is run on "Dominican time." I was supposed to move today to my permanent room while I'm here but instead was told "Don't worry about it! It's Sunday! We will move you tomorrow." :)

I really enjoyed walking around the city without an itinerary, stopping to sit in the shade whenever I got too hot to read a book. I even noticed that since arriving here, I tend to walk slower. Maybe I have a laid-back persona somewhere in me after all!

One of the coolest things that I did today happened by accident. I walked into an academy of sciences that I thought was a kind of museum; honestly I mostly walked in because I was really hot and in need of some shade. Right away, someone greeted me and introduced me to a group of 20+ Dominicans who were meeting for an afternoon intellectual discussion about Freud. They were so excited to have me join them. Gosh, it was so darn cool to hear people talking about Freudism in Spanish!!

I hope to upload pics from my trip this week so I can talk more about the amazing places I visited today. In the meantime, I'm planning to study obstetrics a bit tonight. Tomorrow is my first day of work. Honestly, I have no idea what to expect. It's exciting but also a bit nerve-wracking to think about the huge volume of patients that are seen there and how little I know about what my responsibilities will include. Keep your fingers crossed for me tomorrow!

To all of you back in the US, I hope that you enjoy Superbowl Sunday! I miss the fun parties and yummy snacks... my favorite part of football. :)

Hasta pronto!

Day 1

I arrived safely in Santo Domingo- yipee! I already took tons of pictures but haven't found my USB cord to sync the pics; I will add them once I unpack.

I flew out of JFK early this morning. The people waiting with me for our flight were an incredibly diverse group- native Dominicans speaking quickly and loudly on their cell phones (who were they talking to at 4am?!), native Haitians anxious to return home through the DR for now until airports re-open in Haiti, and lots of energetic and enthusiastic volunteers traveling to Haiti to help with the relief efforts after the devastating earthquakes. The flight went by quickly, mostly due to some interesting people watching and a really lucky comfortable emergency exit seat.

My goals for today were simple- get a cell phone, call home, find a place to stay, be safe. I'm excited to report that all were accomplished easily! :)

My cell phone 1(809)423-4587. It's free for me to receive incoming calls. Please call! Otherwise, I have really incredible access to the internet (phew what would I do without it?!) and can usually be reached via gchat when I'm on my computer.

My hostel is awesome. It is a family-owned hostel who are super friendly and patient with my long-winded Spanish questions. We have a shared kitchen and dining room, lots of terraces... and best of all unlimited free wireless! Having unlimited access to the internet is a huge (and unexpected) bonus. I rely on the internet so much for staying in touch, looking up maps, planning running trails, etc and I didn't expect to have such great access so I couldn't be happier about it. My hostel is a bit more expensive that I had originally planned, but it feels so great to have such a nice safe place I can call home. I'm sticking to my mama's advice ("safety and peace of mind is priceless") and went for a place I can easily call home abroad.

My hostel is an a great part of Santo Domingo called Gazcue. Gazcue is a quiet quaint, tree-lined neighborhood. It has plenty of restaurants and shopping plazas within walking distance. Did I mention that I am <5 minute walk to the ocean?!! I'm also walking distance to the major touristy areas in case I miss being an American one day. :)

I took really awesome pictures today when I walked around my neighborhood. Did I mention that I walked along the ocean for a few hours today? How is that snow treating you, Cleveland??!

I also went to a grocery store today. It was a huge supermarket with tons of options- they even had soy milk! One of my pastimes back home is grocery shopping so I was really excited about my first supermarket in Santo Domingo! My favorite thing about the grocery store was how colorful and busy it was. I just loved that everyone was taking their time and that everything was kind of disorganized forcing you to walk up and down each aisle. I didn't have a grocery list in mind but decided to splurge on nutella ($7!!) and buy some smarter choices too (bread, butter, cottage cheese, pasta noodles, apples, granola bars). Don't worry mama, I will make better planned meals at the next trip. :)

So all in all, it was a hugely successful arrival to the DR! Ok so I may have accidentally been stupid when I decided to peel my apple ( to avoid washing the skin with local water that I'm not used to and could get sick from) with a wet knife; dangit. I really hope I don't get sick on my second day in Santo Domingo. Keep your fingers crossed that I have enough ciprofloxacin and metronidazole to get me through these mistakes!

Sending anyone who is reading this lots of love. :)

Bad at goodbyes!

I'm at an airport hotel near JFK tonight. My flight leaves for Santo Domingo early tomorrow morning. Thank you so much to Meredith, Nina, & Brent for the amazing voicemails and support! I am so lucky to have such wonderful thoughtful friends! I saved your voicemails so I can listen to them when I get homesick. :)

I've finally stopped crying... or at least I hope I have. First, some background. I am a huge sap. When I was 12 years old, my mom drove me to my first overnight camp- it was only 45 minutes away from our home and I was only going to be gone for 5 days. Both of us cried for a good 15 minutes. I guess for whatever reason I never grew out of this- I cry when I have to say goodbye or leave home. Now don't misunderstand me... I like to think of myself as super tough in most situations. When there is a crazy crash C-section, I am calling a code on a patient, etc I am completely calm in an almost eerie way. I guess this is what makes me crying today (and yesterday!) before my trip so humbling. As tough as I can be in clinical situations, I still am a homebody mama's girl who gets scared. I figure that there are a lot of new experiences waiting for me starting tomorrow- it's ok to be nervous about them even if I'm also still really excited about all these opportunities.

Plan for tomorrow: 4am arrival at JFK- yikes! Arrive in Santo Domingo at 1pm. Arrive in my new home for the next month. Get cell phone. Call home (s). ENJOY THE 81F sunshine!! This weekend, I hope to do some fun exploration of the colonial historic part of the capital. I will post pictures later in the weekend if all goes well.

So to all my friends I didn't call back before I left- I'm sorry. I just didn't want you to have to hear me being emotional, I knew it would pass. To David and Olive- I miss you guys so much already; please take good care of each other... and enjoy the snow! To my wonderful amazing parents, thank you for always taking such good care of me, giving me a huge hug and letting me cry it out, but encouraging me to be the strong person I know I can be, too.

Dominican Republic in February!

Hi everyone! Huge apologies for the lack of posts since May (yikes!!). So much has happened since I last wrote- I passed my licensing exams, I finished some tough rotations, applied for residency programs, interviewed at 21 hospitals across the country, enjoyed the holidays in Texas, and submitted our rank list for residency programs! Phew! And of course, there has been plenty of wedding planning going on, too!

Next up on my long to-do list this year is a trip abroad to the Dominican Republic! Back in college, a good friend of mine recommended that I read "Mountains Beyond Mountains" by Tracy Kidder. The book chronicles the life of Dr. Paul Farmer, an incredible physician who is an incredible advocate for social justice particularly in his work in Haiti. His organization, Partners in Health, has lead the recovery efforts after the tragic earthquakes that have devastated the country. The passion with which Dr. Farmer.

"But if you're asking my opinion, I would argue that a social justice approach should be central to medicine and utilized to be central to public health. This could be very simple: the well should take care of the sick. " - Dr. Paul Farmer

I think that my trip to Santo Domingo, Dominican Republic will provide a life-changing experience and I'm honored to be able to serve this population, as well as any Haitian refugees. I feel like my medical school experiences have really come full circle with this trip.

I will be working at maternity hospital boasting 25,000 deliveries a year!

Just so you know, the largest university hospital in the US boasts a "small" 15,000 deliveries a year. Yikes! It looks like I will have plenty of work waiting for me there! I'm really excited to immerse myself in the Spanish language and OBGYN in an underserved population of patients.

I apologize in advance for delays in responding to emails! I will post my phone number in the DR where I can be reached once I arrive in the DR. In the meantime, below is a link to the hostal that I will be staying.
http://hostalbellaepoca.com/eng/contacto.php
Street Cayetano Rodríguez #3, Gazcue.
Sto. Dgo., Dominican Republic
Phone 809.221.1271

Lucky lady :)

I am on my acting internship in OB this month. I'm loving it so far (more details later) but I wanted to post about my first day post-call. I came home today after a 30 hr shift at work. David was at home waiting for me. He understood what it meant when I said that my day was "fine." He understood that we would talk later and didn't take it personally that I was too exhausted to tell him that I missed him. After taking a glorious post-call 3hr nap, I woke up to find out that David had been busy with a special surprise. He went out and got some of my favorite things to indulge in after call- sloppy joes, my favorite beer, my favorite lemonade, scallops for a special dinner. Despite my lack of sleep, I couldn't help smiling and being excited to spend the rest of my day off with him! It meant so much to me that he understood what a rough night of call can feel like and that he gave me time to relax before I talked about my day. And the fact that he did this all while he is on his ENT AI makes me feel just that much more special. I feel so lucky to have such a caring, thoughtful, and understanding fiance! I think that we make a great team. :)

Goal for 25

I turned 25 this weekend. I was worried about turning 25. It sounds old, I guess. I can remember thinking 25 was really old. I guess it freaked me out because I thought that by 25 I would have a job, be living independently (sorry mom & dad), be married, have kids, etc. Instead, I'm still in school, I still shamelessly appreciate my parents driving Cleveland to get me a nice meal and stock my fridge, and have no money in sight for the next decade. Ouch. Instead of worrying about it too much, I tried to be pro-active and think about things that I wanted to do in the next 25 years. So here is my list:

1.) Be healthy & active. It's not easy to take good care of yourself when busy. I want to make sure I make my health my priority. I took a jump start on this goal- I ran a 10 mile race on my birthday morning and got my lifetime best time. :)
2.) Find a job. Get a good residency, work hard, train well, earn a living. Seems easy enough, right?
3.) Learn how to be a good wife. Get married next year, learn how to have a healthy marriage during residency and 80 hr work weeks, don't get too grouchy post-call, make time for each other.
4.) Pay back my parents, somehow. Take good care of them- it's my turn. Help them make each year their happiest & healthiest. Try not to lecture about health stuff too much.
5.) Have kids. There will never be enough money or enough time in my line of work.
6.) Do something for myself everyday. Running, reading, bath, cooking a fun recipe, walking Olive- whatever it is and whatever it becomes, I want to make sure I try to find time for being a healthy happy person
7.) Get back into yoga. It makes me stronger, healthier, happier.
8.) Start swimming again. Join a team.
9.) Keep in touch with friends. Friends from home, college, med school, and beyond- I have met so many wonderful people that I want to keep in my life wherever I go next. There are no excuses- phone/texting/twitter/facebook/email makes it so easy to say hello.
10.) Find a passion in medicine. Love what you do at work and be happy you are doing it everyday (or most days).

Soon to be GRINDLER MD!!!!!

In case you missed it out of all the craziness and excitement, David proposed and we are engaged to be married!!! The week that I got into Case for medical school I got a Chinese fortune cookie that said "there will be big changes but you will be happy." Boy was that fortune cookie right! Since starting medical school, I met David, we moved in together, we bought a dog, we remodeled our townhouse together, we learned how to become physicians, and best of all we are happy! I could not have planned a happier or more exciting three years of my life!

As we continue to move forward in our lives, we plan to get married in early May of 2010, graduate and officially become Grindler MDs in mid-May 2010, and start residency in July 2010! So many exciting things!

I'm working on a wedding website now to talk about how we met and our wedding plans. Contact me for the site!

Karma

On my neurology service I have seen many examples that life is just not fair. A woman in her 30s who had been trying to get pregnant for several years finally does, only to experience a seizure; we scan her head and find that she has metastatic lung cancer. She was a smoker when she was a teenager. Now she is faced with the decision to aggressively treat her cancer and live an extra few months or give her future child a chance even though it will mean that her child will never have a mother.

I have also seen an example of how sometimes the bad things that you have done to others can catch up with you. We had a world famous neurosurgeon on our neurology service as a patient this week. Neurosurgeons are notorious for bragging about the very worst residency lifestyle- on call overnight at the hospital every 2nd or 3rd night, bragging about working 120 hours a week, excited that they were only home for 8 total hours this week. The long years of sleep deprivation and the surgical culture bred throughout training makes many of these surgeons unpleasant to say the least. Our patient this week was a neurosurgeon who suffered a traumatic brain injury after driving intoxicated on his way to a surgical conference. Last week, he was doing life or death procedures on brains and making nurses/residents/students cry on a daily basis on the side. His life as a neurosurgeon was mean- he was well-known for being one of the meanest humiliating surgeons around. This week, he is a patient and is slowly starting to realize how humbling it really is. The patient maintained his bossy cruel demanding personality at first. As he realized the extend of his injury, the long road to rehabilitation ahead, and that he would never operate again despite those long years of training, he became a different man or at least tried to.

I met a neurosurgery resident this week and recognized the name. This neurosurgeon in training had paged me late on a Friday night after I had gone home to yell at me for an inconvenience that my staff physician had made. It was totally uncalled for (I was just a medical student, it wasn't my mistake, it wasn't a big deal) but I remember his name. After I met the patient-former neurosurgeon on our floor I thought of this resident again. Sure, he was tired and it wasn't fair that he was working so late... but how quickly it all can change and you can be at the mercy of your colleagues.

These experiences remind me- life isn't fair sometimes, but sometimes it is. I hope to work hard at being the best person I can be as well as the best physician- after all, they are not mutually exclusive.

A bad day

I'm finishing up my pediatrics rotation and feeling ready to reflect (and have a weekend off!). I have really surprised myself with how little emotion I feel when I'm working at the hospital. I always care about my patients but somehow it doesn't translate to an emotion. This changed when I started pediatrics- everything started to affect me. Before I describe today's bad day, I want to remember that there have been some really special moments in this rotation. I've witnessed and participated in more than 60 deliveries of an infant before starting peds- sure I thought it was awesome and special, but it wasn't until I was on the pediatrics side and when I was the person responsible for this seconds old new person that I realized how special it really was. And another patient I met in the hospital, an adorable 2 year old with some bad luck... I spent 2 weeks seeing her and when she was finally healthy enough to go home, her family left me a heartfelt note describing how much I helped them through a hard ordeal. I liked being able to appreciate how special those moments were.

Today was a day I wished that I could turn off my emotions and not let things affect me. One of my patients, a previously healthy 13 month old came to the hospital for a bad ear infection and today we had to tell the family that their only has a very severe form of leukemia. I overheard mom calling her parents saying, "Mom, pull over the car... are you pulled over? It's leukemia. It's bad. We are going to be the hospital for at least 6 months." I talked to dad who kept saying "He's all we have. Our lives revolve around him. He has to get through this." And after hearing all this, I learned from my attending that this form of leukemia has the most intense chemotherapy and very few kids are able to make it. Today would be a good day to be numb.

More sadness today- a 12 year old healthy child with complaints of diarrhea developed pancreatitis, then we diagnosed a severe inflammatory bowel disease, only to find that he had a cancer that no one in the history of medicine has survived; a baby born premature and with lots of complications is now 8 months old and ready to play but has had no visitors in the hospital so he just stares at the ceiling above his hospital crib; an 18 year old fighting cancer for several years, excited to go to prom this year, learning that her cancer is back and its back for good this time. Although I recognize that today is a particularly sad day, I can't but help thinking that this is too difficult to do everyday for the rest of my life. Although I am glad that I am not numb to sadness, I don't like that I come home and feel numb, so drained. It makes talking to friends and family difficult- how can I chat about what's new in my life when all I can think about are the experiences that have influenced my day? So basically, even though I've had some unbelievably positive experiences in peds, the few bads ones make me cross it off the list of career choices for me.

A gut feeling

On my surgery rotation, my energy and hard work was appreciated but I didn't quite feel like I fit in. When I asked my colleagues on general surgery what they thought I would be "when I grow up," I had several people tell me that I would undoubtedly love Obsterics and gynecology (OBGYN). I have always appreciated forming strong doctor-patient interactions in clinic, something that I really missed during rushed general surgery clinics where patients became a nuisance and their questions just slowed us down. I didn't just want more patient interaction, I wanted more meaningful interaction with my patients. That said, my love for surgery taught me that dedicating my life to clinic like a family practitioner wouldn't be enough for me. My colleagues noticed in me that I wanted to pursue a career in which I had the best chance at being a real practicing surgeon- a physician who is able to perform a surgery and really take care of them afterwards. They saw in me a future OBGYN. I wasn't sure about the idea because I hadn't done my OBGYN rotation at the time, but I was very excited to start.

It didn't take long for me to realize that my colleagues were right. In fact, on my first day of OBGYN I had the revelation: this is what I want to do with the rest of my life. Almost instantaneously, everything fit. I loved working with women. I loved the challenges of pelvic anatomy. I loved that all of the procedures performed in the operating room had significant meaning that I would have to follow up with important discussions with the patient. For example, I had a hard time getting excited about reducing a hernia on general surgery. What was the point in spending time with the patient afterwards? Instead, in OBGYN my patients were having emergency C-sections to rescue their babies or exploratory laparotomies to remove a suspected cancer followed by hysterectomies. I loved the importance and meaning of everything I did in the OR. I loved that afterwards, I got to really talk with my patients and help them understand what happened in the OR and why.

I have really enjoyed all of my clinical rotations. I have a passion, however, for OBGYN. This field makes me feel more alive. I am excited to go to work everyday with this field. This field makes me feel like it's all worth it. This field makes work seem easy again. Oh my goodness- I think I'm going to be an OBGYN!!!!!!!!!! :)

On death and dying

My experience in general surgery and trauma calls at night immersed me in a world with really sick people, some of which ended up dying. My first experience with death was overnight on trauma call. A man came in as a "cat 2 MVC + EtOH" meaning he was like most of our trauma patients at an inner city hospital- drunk, driving, and badly hurt. After securing his ABCs (airway, breathing, circulation), we saw his only obvious injury was a broken arm. He started becoming more agitated and it took almost 6 of us to hold him down so that we could finish our exam for injuries. A few moments later, we realized that he had no pulse and that his heart was no longer beating. I started chest compressions on him for what seemed like forever (in actuality about 3 minutes). As I was beating on his chest I couldn't help thinking that I was keeping him alive at that moment. I didn't expect the chest compressions to work- I had heard of the statistics that less than 10% of patients who receive CPR make it out of the hospital alive- but somehow miraculously he re-gained a pulse. He was brought back to life. We re-evaluated his injuries and discovered that he had an acute abdominal bleed. His blood pressures started dropping and we realized that he would need to go to surgery immediately to try and stop the bleeding. I helped transport him into the operating room. He lost his pulse again. We started chest compressions again but realized that stopping the bleeding, and not keeping his heart pumping was his best chance at life. Without much time for the usual sterile techniques and precautions, we essentially sliced into his abdomen and 3 L of blood gushed out of his abdomen, soaking us all. We quickly surveyed his injuries and realized that they were too severe to correct, he still had no pulse, and there was nothing we could do for him. He was pronounced dead a little after 20 minutes when I first met him. I helped sew up his abdominal incision and couldn't help myself from thinking that just 20 minutes ago, I was talking to this man, hating him for being so agitated so drunk so careless. Now, he was becoming cold and stiff as I finished up his sutures. Now, I realized that I had seen life leave a person's body for the first time.

After watching so many episodes of ER and other medical TV shows that dramatize what I did for the past 4 weeks, I can now appreciate why so few physicians watch them. The truth is, after crying after watching a patient die on TV, I had no emotional response to seeing my first patient die. I felt numb. I wanted to feel something. Instead, I went on to work up the next trauma that night and went on to the regular OR cases later that morning. I always thought that death and dying would really affect me and my ability to practice certain types of medicine. Instead, almost instinctively, I became numb to it all. Almost instinctively, I adapted the same coping mechanisms for dealing with death (dark humor, sarcasm, indifference) that I had promised I would never have. And despite the fact that I wish I could feel differently about my first patient's death, I realize that if I had let it get to me, I would have had a difficult time continuing to work and finishing this rotation. I'm not really proud of who I became over these past few weeks but I felt that I had to in order to get through all experiences that were thrown at me.

In the end, I witnessed 4 patients die on trauma call and I was responsible for withdrawing life support for one of them. It never become easier to witness death but I did stop searching for an emotional response. I hope that a few days from now, once I've caught up on my sleep, I can reflect on these patients and their deaths... and maybe even have a good cry to prove that I'm not numb after all.