Motivational learning

As I watch another hysterectomy, I can’t help but think of all the skills and facts I don’t know. Why does the surgeon cut the broad ligament first? Why did he make a vertical incision instead of a horizontal one? How does he select the #1 suture instead of the #2 suture? How can he stand on his feet for so long!?!

My motivation to study and learn grows every time I stand in the operating room or adjacent to patients’ beds during rounds. As my “trip” in East Africa winds down, a new motivation to study and academically succeed grows. Hit those books. Write those notes. Attend those lectures. Watch them again!

How do I maintain this energy in the middle of the school year when I’m filled with stress, fatigue, and junk food? My first year punched me in the face because I lost motivation to persevere. Though I did well enough, I could have done better, and I think the key to improvement involves reminding myself why I’m doing this. I need to get clinical exposure at least once a week throughout the school year.

Our hospital back in New York offers a plethora of opportunities to see patients – even if it is behind Plexiglas. I can watch surgeries. I can volunteer. I can shadow professors. I can conduct research. Also, a friend of mine from synagogue volunteers at the local HIV/AIDS non-profit and offered to get me in.

I never found the need to do this last year; I resorted to my usual undergrad habit of running several student organizations and planning events, which I enjoy. However, if I plan to stay sane during the trials of the next 10 months until my USMLE, I will need to switch my extracurricular priorities.

Bike Challenge

You can always count on two things: family and connections. A nice doctor from KCMC connected me with a bike provider. Suddenly, my bliss knows no bounds.

Isn’t she pretty? She was placed in my care for love and good keeping for my last few weeks, and on the first day, daddy felt obligated to take this baby for a test spin around the block.

However, it wasn’t easy. During our maiden voyage, I realized that we weren’t living next to a mountain for four weeks; we were already on one. The roads either sloped downward in a crazy-fun death spiral or climbed painstakingly upward. At many points I had to stop and walk until I regained my breath.

How do I overcome this? Was the seat too low? Was I that out of shape? Is Moshi, Tanzania bike un-friendly? As I rode upward, I looked over and caught a glimpse of a 19,334 foot-tall friend in the distance. It finally decided (after a week) to poke it’s head out of the clouds. I was able to capture it from the seat of my bike.

That’s when I realized that climbing this hill will require more than a seat adjustment; it will require an attitude adjustment. I plan to keep riding this path as often as I can until I can make it up the hill without having to stop.

Then, a new challenge was born.

First Year Going On Third.

Excitement. I’m preparing to present my first patient (and her newborn) during the daily morning report.

In lieu of my research failure, I’ve taken the opportunity to learn as much about Obstetrics and Gynecology as I can on the wards. I’ve watched many surgeries, seen many patients, and read many textbooks.

I’ve been reading the “First Aid for OB/GYN” – the bible for third-year students rotating in the OB/GYN department. I’m attempting to turn my “shadowing” experience into a mini third-year rotation, where I actually get involved. I can’t tell you how gratifying it is for your attending to mention the types of abnormal vaginal bleeding, which you have already studied a few days earlier.

Without formal training, I can’t do most tasks like IVs, blood draws, cleaning wounds, etc. However, two weeks ago I was allowed to scrub in and assist the surgeon with surgery. It was an abdominal hysterectomy and my first time touching a uterus. The entire experience filled me with excitement as I assisted the surgeon clamp, cut, and sew.

Yesterday, I was allowed to assist in a cesarean section for the first time. After observing a few (and years of hearing the story of my own cesarean birth), the speed of the procedure took me by surprise. The cutting didn't elapse as long as the anesthesia. After a few minutes of cutting and some blood-splattered scrubs later we were able to deliver a healthy baby boy amidst a sea of meconium, blood, and amniotic fluid.

It was both amazing and disgusting at the same time. I have joined the club of those who have placed their hands inside the uterus of a woman he or she didn’t know (though I did know her vital signs).

After the delivery, the hard part began. The surgeon delivered the placenta, and we both started the process of cleaning, patching, and sewing. After we finished and both patients were transported to the right places, I got the third-year honor of presenting this patient to the rest of the OB/GYN staff.

Simple Pleasures

When one settles in an unfamiliar culture in an unfamiliar country (especially a developing country), he or she finds refuge in simple pleasures to help with homesickness.

A popular source of refuge for me involves food – lots of food. In a sea of beans, rice, ugali, chili sauce, and mangos, I appreciate the opportunity to have a hamburger once in awhile – or even better… waffles and ice cream!

They sell this at a coffee shop down the road from our house. What I’ve really enjoyed about this particular dish is the richness of the waffle. They must put some form of cream or cool whip in their batter to make it extra thick. Yes, it is more expensive than the beans and rice we could have purchased (though still cheaper than New York prices), but tasting the comforts of home is worth the money!

Furthermore, what’s a lazy weekend afternoon without a nice, long run to remind you of home! In New York, my running paths took me either to Central Park or to the East River. Here, my running paths always take me to see Mt. Kilimanjaro among a sea of sunflowers, which makes it worth the sweat, fatigue, and panting.



The girls, on the other hand, have found their refuge in tea – for good reason. Most nights are often spent enjoying several cups of hot tea and a good novel. Par chance, I visited an attending physician’s house and spied his collection of Sex and the City DVD’s. I knew the girls in the house would enjoy a marathon of Seasons one through seven. I had only seen a few episodes, but seeing New York City again (even if its on a fake TV show) appeals to me. This is the third week of our marathon.

I don’t want to go back and start school!

A Crazy Idea

I have a fantasy; let me disclose it to you. I want to circumvent Lake Victoria and visit the surrounding cities.

This desire probably stems from my admiration of road tripping – traveling on the go. Also, as a person who grew up near the Great Lakes in Michigan, I hope to see this “other” great lake they keep talking about.

My dream trip will probably go something like this (click on the photo for a better quality):

Day 1: Take a bus from Moshi, Tanzania (Point G below) to Nairobi, Kenya (Point B), get a hotel, and experience its infamous nightlife.
Day 2: Explore Nairobi during the day and learn more about its blossoming art scene
Day 3: Take a bus to Kisamu, Kenya (Point C) and see Lake Victoria for the first time.
Day 4: Take a bus into Uganda and travel to Kampala (Point D), it’s capital city – also known as the “Pearl of Africa” (courtesy Winston Churchill).
Days 5, 6, & 7: Meet up with a two medical school friends and explore Kampala. Also, visit Entebbe (on the cost of Lake Victoria) and Jinja (where the Nile begins). We’ve discussed the possibility of white water rafting!
Day 8: Via bus, trek around the western edge of Lake Victoria into Tanzania to Bukoba (Point E).
Day 9: Travel to Mwanza, Tanzania (Point F). In lieu of a bus as indicated on the map, I intend to take a cross-Lake-Victoria ferry.
Day 10: Set off on the final branch of the trip: a 12-hour bus ride back to Moshi, exhausted and gratified.

Because transportation is often unpredictable, who knows if this plan will work or how long it will take, but I can’t give up the prospect of visiting all these cities.



However, there is a caveat. I will most likely do the traveling alone…

Part Three: Ngorongoro Crater

Formerly a volcano – now collapsed and inactive. Our campsite overlooked the crater and chilled us to the bone. The temperature at night fell to 12-15 F.

When we first arrived, we encountered a surprise: two thirsty elephants! They often visited to drink water from the campsite’s water tank (in between the two elephants in the first photo). One walked among the tents for a bit before leaving.

The following, bone-chilling morning we paid the crater a visit. Despite the chills, this place easily became my favorite of the three parks – abundant animals, endless clifts, and spectacular views – especially the sight of cloud shadows. Whenever I think of God, my mind’s eye pictures this:

Lions. Lions. Lions. They ruled the place and knew it. Though today must’ve been their day off because all they were all napping. We even found a couple lions lounging in the middle of the road. The approaching cars only succeeded at making these lions even sleepier. We had to drive around them, but again appreciated the proximity. Our guide, during lunch, described a scary moment when a lion once jumped on the hood of a truck and fell asleep – he apparently liked the warmth of the engine. The lion was so heavy that when it finally left a dent in the hood remained.

Again. Kings of the jungle!

And here are its subjects: wildebeest, zebra, ostriches – we had a fun time.

More photos:

Lion cubs!

Part Two: Serengeti National Park

Siringit = endless plains in Massaai. 14,763 square kilometers of endless plains grazed by tens of thousands of wildebeest during their annual migrations. We visited during the dry season (June to November) and easily spent two days here. Every tree, animal, cloud reminded me of the movie the Lion King. I’m not sure why they don’t sell it at the gift shops here.


Our first animal of the park: the superb starling. The metallic blue-green feathers caught my attention. However, I saw hundreds of them over the next two days, and the novelty wore off.

More elephants. We spied another grazing herd move through the plains. I adored the proximity.

More acacias. They never get old.


We arrived at our campsite for the night and caught the sunset while fighting off mosquitoes. Also, a hyena paid a visit to our campsite during the night. My classmates were worried, but I slept through the entire thing.

We arose early enough to see the sun rise and spy a few more animals. We saw lions from afar, though we saw most of them the following day at Ngorongoro Crater.

Safari: Part One

If given the opportunity, how would you describe the universe? Would you start with a physical description of its stars and move forward to the galaxies? Would you explain the universe in the form of a story from beginning to end? Would you be concise? Is that even possible?

If you replace “universe” with “safari,” you have my problem. We finished our safari tour of three national parks a week ago, and I’m still racking my brain to figure out how I can describe the amazing things I’ve experienced with you all.

I’ve decided to rely on pictures with a few highlights. Brevity is the soul of wit.

Part One: Lake Manyara National Park

Less famous than the other two, this park is known for its birdlife and abundant hippos. The park lies between the lake and a series of cliffs that resemble the hills of Los Angeles – we looked for the “Hollywood” sign.

We awoke at 4:30 to be picked up at 5:30 from our compound by the vehicle below. The first night we slept in a luxury lodge; we would camp the following two nights.

We (and our stuff) waited to start an adventure!


Hippo pond – with storks, hawks, wildebeest, zebra, and of course, hippos. This is what I call an ecosystem.

While driving around, we spied the rear of an elephant snacking on a nearby bush. While verbally coaxing it to turn around, we almost missed this family of elephants behind the truck! They sprinkled themselves with dust to “clean” themselves. How it works, I have no clue.

An acacia tree – the symbol of both East Africa and the movie "the Lion King." Often, we would break into song.

The velvet monkey. The first thing I noticed were the bright blue genitals. That’s how you can tell its aroused, apparently.

What I wish I had done differently

To anyone who is traveling to East Africa: bring a ton of cash in US currency! Not just cash, but $100 bills. Here’s why:

• Credit Cards are useless here. Everywhere I ask about using a credit card (restaurants, stores, etc.) I just get laughs. Plus ATMs do not withdraw US dollars, only T shillings (T /=), of course.

• ATM’s mostly Charge. This may come as a surprise to some people (it was a surprise to me), but there are ATMs in Tanzania, and you can withdraw money from them with your American debit card – for a fee. It depends on your bank, of course, but I (and my classmates) are charged a 3%conversion fee for every ATM withdrawal. Some banks, charge a flat fee of $5 dollars on top of a 3% conversion fee. Go figure.

• The exchange rate is much stronger for $100 dollar bills. When I arrived in Dar Es Salaam, the best exchange rate I could find was 1465 T/= (T shillings) for $1USD, but that was only for $50 and $100 dollar bills. For USD$20, $10, $5 dollar bills, the exchange rate was a mere 1420 T Shililngs per dollar.
  
• ...Furthermore, to buy back US dollars with T Shillings, you pay more: 1520 T/= per US dollar. For example, if you had $100 US and you wanted to exchange that for T Shillings, you would receive (100 x 1465) 146,500 T/=. However, if you wanted to take that same amount of T Shillings and exchange it for US dollars, you would recive only (146,500/1520) $96.38 – you would lose $3.62 for each 100 US dollars. This is illustrated in my next dilemma.

• Many touristy expenses charge only in American Dollars. This includes excursions, hotels, hostels, travel agencies, and some (but very few) restaurants. For example, My classmates signed for a four-day safari to both Serengeti and Ngorogoro national parks. The Tanzanian-based company that is organizing our trip charged us $530 US dollars. However, I didn’t bring enough American currency with me from New York, which forces me to buy back US currency with T Shillings. The exchange alone will cost me an extra [(530x1520)-(530x1465)] 29,150 T/= (or $ 19.90 USD). I should have brought more American currency.

I think the last bullet point is especially strange. I never knew the power of US currency in this country. Even those from European and Asian countries who travel to Tanzania must exchange their euros, pounds, yen, etc. for US dollars before leaving their home countries if they expect to go on bike trips or safari trips.

That’s American privilege.

Research Failure

When I decided to work at KCMC in the Obs and Gyn department, it was with the expectation that I would assist with an ongoing research project that assesses methods to prevent mother-to-child HIV transmission. In New York, if a new mother is HIV positive, we would just encourage her to avoid breastfeeding her child (which can transmit HIV) and use a formula for her child instead. However, in a developing country like Tanzania, one can’t guarantee a stable, clean water source with which the mother can make formula. Hence, the mother risks transmitting fatal diseases, like cholera, from the potentially-polluted drinking water – especially if the infant’s brand-new immune system lacks the antibodies necessary to ward off these diseases.

To prepare, I’ve read a few studies from Malawi and Botswana that discuss the usage of prophylactic HIV medications to prevent the mother from transmitting HIV to the infant with good rates of success. I was hoping to participate in a similar study at KCMC, but to my dismay, I was informed that no such project exists anymore at KCMC! I must’ve come too late. When I asked about other research projects in the OB/GYN department (including the famous Pre-Eclampsia/Eclampsia project), they either have already been completed or were awaiting approval. I was in shock. My classmates, also hoping to assist with some sort of research project, experienced similar disappointments.

Now, I’m considering the possibility of spending six weeks shadowing physicians, which isn’t unappealing. The staff and faculty of the OB/GYN department have been really helpful. One physician offered to give lectures on important topics in OB/GYN.

I could also use the spare time to conduct research of my own in the library. Giant obstetrics, surgery, medicine, and physiology textbooks await.

Now, I'm updating this blog on real time. I go for a four-day safari tomorrow. Can't wait!

Obs & Gyn

… in Tanzania; Obs and Gyne (pronounced guy-knee) in the UK; and OB/GYN (oh-bee-guy-nn) back home in the US. No matter how you abbreviate it, obstetrics and gynecology is an interesting and interdisciplinary medical field.

Though obstetrics (the medicine of pregnancy and childbirth) and gynecology (the medicine of the female reproductive tract) are two separate fields, they intertwine very closely. Hence, most doctors specialize in both, which gives the OB/GYN field the multifaceted approach I especially enjoy.

In fact, at the age of 13, when I first considered medicine as a career, I wanted to be a gynecologist. I told everyone. The initial interest stemmed from my mother’s explicit descriptions of puberty, birth control, menstruation, childbirth, and pelvic exams; explanations that would have terrorized any pre-teen fascinated me. At 14, I built an anatomical model of the female human body, which still resides in my room back in New York. One could change the breastplate, intestines, and uterus to make the model 7 months pregnant.

The 9 years between those awkward adolescent moments and my first year of medical school have seen multiple changes in both career aspirations and academic interests – including serious time commitments to both HIV/AIDS issues and mental health issues. However, OB/GYN (and women’s health in general) has always held a special place in my heart.

In college, as I developed other medical interests, I’ve looked away from OB/GYN. Mental health is a heavily overlooked issue I desire to pursue, first of all. Also, the medical malpractice insurance for OB doctors is ridiculously expensive in the US (in the range of 150,000 to 300,000 a year), and not many doctors are compensated enough to cover such an egregious expense.

I decided to work in the Obs and Gyn department at KCMC this summer to acknowledge my initial interest – and because it is more difficult to shadow a psychiatrist in a country where everyone speaks Swahili.

Let’s see how it goes!

KCMC

Today (6/30/2010), we visited the Kilimanjaro Christian Medical Centre (KCMC) for the first time. I spent $385US dollars to pay for housing ($150 a month for 6 weeks) and $140US for a residence permit. The rent also covers the cost of having a house cleaner, who comes in and does yard work, washes the dishes, makes the bed, etc. For an extra 5000 T/= (or T shillings) per week, she can wash and iron your clothes.

KCMC is a major teaching hospital with a medical school (one of three in Tanzania) and a nursing school. Many patients travel a great distance to receive care. Because Tanzania is a developing country, disparities are apparent. For example, because the surgery department has limited supplies, we were instructed to bring our own scrubs, masks, and caps if we intended to observe a surgery. Blood supplies are drastically low – I plan to donate blood soon. Furthermore, the internal medicine department lacks a working EKG machine, and because there is no full-time pathologist, pap smears aren’t given to test for cervical cancer (I will discuss this topic later).

Despite the disparities, the hospital is full of talented and caring people who truly work hard for the benefit of the patient. Unlike any other hospital I’ve seen, the campus has many open spaces and courtyards. In the middle of the main building, a grassy courtyard beautifies a hallway for doctors, nurses, assistants, and patients. Plus, you can see Mt. Kilimanjaro from the campus.

The next day, I start work in the obstetrics and gynecology (OB/GYN) department. The schedule varies. Some days I start at 7:30am with the morning reports; other days, I don’t need to arrive until 9am.

I can’t wait to start!

"Vacation" Turns Into "Trip"

(06/29/10) Rested, relaxed, ready – our third and final day on Zanzibar marked the end of our vacation. We had to start our trek to Moshi, Tanzania to work at the medical center.

We left Zanzibar at 8:30pm and boarded an overnight ferry back to Dar Es Salaam on the mainland. Usually, ferries between Zanzibar island and Dar take up to 3 hours. However, to save hotel money, we took a ferry that would drop us off at Dar at 6am the following morning. As we boarded, veiled women, anxious children, and working men watched us climb the stairs into the VIP section, where the other Mzungus stayed. The conditions were detestable – cramped spaces, constant rocking, unusable bathrooms. I just wanted to get to Moshi.

When the boat docked, we were greeted by a sleepy town and Alpha, a taxi driver. I called him to pick us up from the ferry and shuttle us to Ubungo, Dar’s bus depot. It’s a crazy environment filled with bus workers, passengers, and pickpockets.

A classmate managed to have us pay 28,000 T shillings for a “luxury-class” bus that would arrive in Moshi at 1:30pm. Ha. The bus was cramped, and we arrived in Moshi at 7pm in the evening (total travel time of 22.5 hours). We saw many cool things on the way, including a crashed plane on the side of the road, which caused the traffic to back up for about half an hour. These are pictures we took from the bus:

Now we have arrived at our house, which I will talk about later. Now, I need a shower.

Zanzibar Spice Tour

Waking up in Zanzibar without having to pack up and travel to another continent meant paradise. I could leave my arduously heavy luggage in the room and move up to the roof for breakfast and view the city.

We soon left for a spice tour that morning – one of the highlights of any Zanzibar visit. A van took us north to a rural part of the island, where a tour guide showed us the numerous spices, herbs, and fruits that grew in this tropical land. We saw vanilla beans, nutmeg, cacao, lemongrass, peppercorn, etc. – with samples to taste of our own. I really enjoyed the aromas!

After the tour, we were taken to a compound, where lunch was served: rice with curry and nan (an Indian form of flat bread). In lieu of the food, I especially enjoyed seeing rural Zanzibar – my first time in a truly tropical environment since I lived in Hawaii as a young child. Many scenes reminded me of Hawaii.

We were soon escorted to a beach, where we got to swim in the Indian Ocean! The water was very salty! It reminded me of those glasses of salt water that my mom made me gargle as a kid. The bottom of beach mostly consisted of prickly coral remnants, which succeeded at scraping one of my toes.

When we returned, we caught another glimpse of the sunset at Forodhani Gardens.

Like I said, paradise.