Omnipotence of Disease and Defenses, Alike

Pediatrics- the object of my obsession for the past couple of decades has finally been a journey that I have traveled through. Upon entering medical school, I was convinced that I would be a pediatrician; however, my goals were later shifted toward family medicine and yet again pediatrics has been thrown into the mix. Pediatrics was 8 weeks of giggling and crying, greater than 10 hour shifts and chronic hand washing/mask wearing. It was the rotation I was warned would infiltrate my body’s immune defenses and give me some odd stomach bug or chronic cough, but one that left my immune system unscathed only to infiltrate my heart, heighten my senses and make my smile one size bigger. It is a rotation I will forever be fond of and a rotation that has truly demonstrated the vulnerability of young minds and the courage they are capable of wielding; the purity of a child’s soul and the darkness that is capable of tormenting the pre-disposed; and finally the joys of health and the suffering of the sick. It was an experience that brought a whole new meaning to one of my favorite quotes from the ever popular Hunger Game series that states, “My mother tries to save the strongest [medication] for the worst pain, but what is the worst pain? To me, it’s always the pain that is present.” This clerkship has driven me to develop a new appreciation for the expansive capabilities of pain penetration and perception. I must admit it is much easier (for lack of a better adjective) to see adults suffer, and let me add that watching an adult suffer is not easy. I also developed a fear for the irrational and unjust behaviors of Illness, and how it unashamedly creeps into even the most wholesome of souls.

 

UNM’s pediatric department is filled with literally some of the best doctors I have had the privilege of working with. They are full of innovative ideas, knowledge, enthusiasm and humor. There were times when I felt like they were “my people,” a description known to all my fellow Grey’s Anatomy fans. I remember warmly a moment where we all eagerly stood in front of the long window in Tully Conference Room and longingly stared into the distance as balloons of all shapes and sizes participated in New Mexico’s famous mass ascension. I was pleased to share in the excitement of these people. I was pleased that they hopped around like little kids, just as my natural response led me to also do.

 

 

 

I am reminded of a time in my pre-medical school life when I participated in a Sacred Sites class, or rather a hands-on honors course dedicated to the study of religion. At one of the sacred sites, we visited with a Native American man who graciously shared his sweat lodge with us on one late afternoon in May. I remember how he discussed the importance of the number four- there are four directions, four seasons, four stages of life and so forth. Since then I have been not only fascinated with this idea, but also more cognizant of the power of four and avenues for application. I feel that using this golden rule is a unique approach to further dividing the overly broad field of pediatrics. Pediatrics is simply considered the specialty devoted to the care of little people, or more specifically those under the age of 18. But imagine the diversity in of itself in those short 18 years of life? It is immense with one end of the spectrum focusing on newborns who are precious in many ways, but capable only of eating and sleeping and the other end dedicated to the enormously complex mind of a teenager who struggles with the vastness of identity, the mysteries of puberty and the struggles of conformity. For this reason, I will use the idea of a culture foreign to my own in an attempt to organize my thoughts. Forgive my naïve approach. As a non-parent, I am attempting to categorize those little creatures whose only opportunity for familiarity is my very own little sisters and those little buggers aren’t the most normal prototypes for comparison. My categories include the cradled and crawling, the sponges, the becomers and the enigmas.   

 

1. The Cradled and Crawling

My interaction with the smallest forms of human life was one that began with comfort struggles and one that ended with vengeance over comfort as I conquered my first solo surgical procedure. Babies flooded the newborn nursery daily, leaving as quickly as they had come. New families were created and existing families were made larger. I was challenged with performing the newborn exam and quickly became a pro at determining the age of gestation and comforting a crying baby. It also triggered a memory of the first newborn exam I had seen performed. It was 7 years prior following the birth of my baby sister- Mistidawn. I remember the pediatrician, Dr. Bunch (my first mentor and role model), as he not-so-gently handled my newly welcomed sister. He quickly and haphazardly undressed her as Deidra and I sighed because we had just spent the last hour meticulously changing her diaper and clothing her while also being terrified of the fragility she exuded. I was now on the other side of this seemingly tortuous exam, and I was the one being stared down by concerned family members. Initially I struggled with this exam, because I approached every maneuver in an overly cautious manner, but within two days I was handling those little newborns like small sacks of potatoes. You might think this is outrageous, but it’s actually a skill that necessitates rapidity and efficiency while also maintaining a delicate touch. I further demonstrated my continuously evolving confidence by performing a circumcision completely solo.

 

Also during my interactions with the cradled and crawling, I unfortunately witnessed the cruelest forms of abuse. The baby was but weeks old when he had been violently shaken suffering over a dozen fractures. I remember the first time we entered that room. I stared at the small infant in his crib, uncertain what to feel, but wanting to feel nothing. This precious little boy surprisingly did not suffer any lifelong injuries, but he did lie there in his hospital issued crib with an extremely elevated heart rate and mute as can be. I worried that he had been punished for crying, and now was trapped in silence, cradled only in an unconscious fear.

 

2. The Sponges

The sponges are the little munchkins that run from point A to point B rather than calmly walking. They repeat every word they hear and they learn to imitate older siblings, good or bad. Take my youngest sister, for example; She used to hold up the peace sign with her miniature fingers just as her older brother did, and so when I was attempting to explain to her the reason our sister, Jelly, had to miss Thanksgiving to serve our country in Afghanistan in order to establish world peace, she looked at me somewhat confused and threw up the peace sign. I longed for a reality that was as simple as those two little fingers separated by a couple inches of air.  

 

I ran into many “sponges” in the clinics and hospitals, and I first handedly experienced the reality of “kids saying the darnest things,” like when a young boy with flu-like symptoms told me his veins hurt. I was fascinated by how his developing brain with a large majority of unmyelinated fibers was perceiving illness. I also interacted with another kiddo with Cerebral Palsy. He was bound to a wheelchair, one of the smallest I had ever seen, and he was slumped over in obvious pain one week following an extensive bladder surgery. As I gently examined him, he opened his eyes only briefly, stared straight into mine and politely asked, “Can I listen too?” while pointing to my purple stethoscope. I gladly placed the ear buds into his little ears and held the stethoscope over his heart and over mine. I was happy to use medicine to bring a much needed smile to his face. Another demonstration of imagination was when I visited my young patient with scruffy hair, big front teeth and mastoiditis. This young boy who had a rare immune deficiency was all too familiar with being hospitalized for his numerous infections, and had even developed his own medical lingo, which is much more entertaining than our Latin-based terminology. One morning, as I asked how he felt throughout the night, he replied with “I was armadillo-ing all night.” My puzzlement must have been obvious, because he was quick to explain that “armadillo-ing” is the act of crawling into a ball when experiencing pain. I couldn’t help but chuckle and later shared the new addition to my lexicon with my fellow colleagues. Little did I realize, I was participating in reverse spongosis- my very own neologism to describe the process of absorbing some new piece of information from a sponge.

 

Unfortunately, there were also sponges who absorbed disturbing medical experiences. During preparation for a tonsillectomy and adenoidectomy, a young Arabic child who spoke only her native language sat in a room surrounded by her parents and doctors who purposefully spoke only English to discuss the procedure she would soon undergo. Her parents had requested that an interpreter not be present from start to finish as they did not want to disclose the fact that their daughter would be in surgery. It was a cultural wish that would be respected, but one that I felt was far from ideal. As I stood there in the Operating Room doing my best to be helpful, I zoomed around moving things to and fro and allowing my eyes to dart back and forth between the task at hand and this obviously timid child. We locked eyes multiple times, but it wasn’t until the anesthesiologist began to hold the mask over her face to initiate general anesthesia that she began to kick and scream at the top of her lungs. Her tears must have been pre-formed, because they immediately flooded down each cheek. The OR staff gently yet assertively restrained her and this only further prompted her to thrash about in every attempt to escape the blue-gowned aliens. I rushed over and whispered the only few Arabic words that I had learned while vacationing in Egypt. “Marhaba habibi” (Hello sweetheart) were the last words she heard before quickly drifting into oblivion, and words that I hoped had given her some peace before waking up to the worst sore throat of her life and once again surrounded by the strange people who had held her tightly and used their medicines to bring about a restless sleep.

 

3. The Becomers

The Becomers are the pre-teens and just before. They’re the most awkward of all the groups and they’re considerably impressionable. They begin to develop their own sense of style. They unknowingly put more thought into the selection of their friends, and characteristics become permanent pieces of their lifelong personality. So when they have grave and incurable diagnosis like leukemia and Neurofibromatosis, these crucial moments of development become augmented with a sooner than normal demand for maturity and worry beyond comprehension. And when these needs are not met, understandably so, their world continues to go further awry.

 

I had entered her room that morning and knew nothing more than the gossip that had traveled through the doctor’s workroom. After a home nurse had visited this young girl in her Gallup home, the nurse was startled with a barely readable glucose level of greater than 670. The family was urged to quickly head to UNMH, and since then the word had spread that this 12 year old previously diagnosed with leukemia and complicated by Diabetes brought on by her cancer treatment had refused to inject even a single unit of insulin into her body. Whispers roamed the pediatric wing about possibilities of contacting Child Protective Services. The young girl with a mostly bald head and pink punk rock clothing sat in her bed with the thin hospital blanket up to her chin. She looked at me and even smiled, but throughout the entire interaction she relied solely on shaking her head yes or no. I felt conflicted. This young girl was undoubtedly harming her body by walking around with outrageously high levels of glucose. But was she taking a stance against her disease in an attempt to feel in control of her situation? Or was she merely in denial? I’d like to think that she was using what little power she had over her situation and she was strongly choosing to do something, even if that something was nothing.  People were furious that she was refusing insulin, but could we sincerely put ourselves in her shoes and understand where she was coming from. I thought back to the 12 year old version of me- I was obsessed with cheerleading and student council, I loved having sleepovers with my favorite girlfriends and I freaked out over a simple pimple on my face much less a completely bald head and having a cancer stigma attached to me. I felt as if we had unrealistic expectations for this young girl. Sure were wanted a mature and strong reaction to her disease treatment, but illness was penetrating her ability to become- to become the best volleyball player on the team, an innocent girlfriend of the boy in math class, or the student council president. Her life in such a short time had become doctor’s appointments and hospitalizations, agonizing nights of dealing with chemotherapy side effects,  and being many miles from her community. She couldn’t become her, because she was too busy becoming who we wanted her to become- a compliant, mature, completely rational patient constantly on the verge of death.

 

4. The Enigmas    

The fourth and final pediatric group is one that is composed of highly complex and nebulous individuals. I saw enigmas ranging from 15 year old girls with serious and even lethal diagnoses still confidently (and rightfully so) making plans for their futures, and 16 year old boys who were already abusing multiple illegal substances.  I saw an 18 year old who had just attempted to end her life by swallowing a bottle of her mother’s anti-depressants. I remember telling her about all the amazing adventures I’ve had since I was 18 in hopes of reminding her how much she has to look forward to. By the end of the long conversation, I had her telling me she wanted to be a doctor when she grew up. Unfortunately, it is the most outlandish of enigmas that remain in my mind. Like the young teenage boy who defiantly spit into his surgical wound in an attempt to draw attention to himself, a statement he made clear while staring into my eyes with such intensity I thought I might turn and run the other way. He was a boy who unashamedly shared his devilish ways and also one with a solid command of the English language choosing each word meticulously so as to manipulate the person at hand. And when he demanded pain medication, he proceeded to tell me he was allergic to Tylenol, aspirin and all the other “baby” analgesics out there and for me to make sure he for the “good stuff.” He was an enigma entangled in defiance and opposition, an enigma I, along with the rest of the world, would never understand.

 

Another kid was an abandoned 17 year old boy who was brought in by his aging grandparents in hopes of finding a better answer to his rapidly progressive isolative and odd behavior. Grandma and Grandpa described him as a once loving grandchild who loved to sing and play. Now he was withdrawn and spoke only minimally. He heard voices, his language skills were deteriorating and he had quickly been transferred to Special Education class. And worst of all his older twin brothers, as well as the rest of society, were quickly beginning to shut him off. The young boy had already been given a diagnosis of schizophrenia, a diagnosis that was strongly based given the history of his schizophrenic mother who had abandoned him and his brothers when they were children. He met all the criteria, yet the grandparents were in search of more pleasing diagnosis, one that did not commit him to a lifetime of shame, medications and dependence on others. They frustratingly shared how they needed a cure, because there wasn’t a single soul in the world who would be capable of caring for him as they approached an elderly age necessitating care for themselves. They cried when they explained that his older brothers had no interest in offering support, and so an affirmative diagnosis nearly crushed their hearts. He was an enigma trapped in his own mind, an enigma his grandparents loved dearly but feared losing.

 

 

 

 

In the end, I learned that pediatric patients are susceptible not only to the physical changes of illness, but they are challenged with the emotional and psychological aspects even more so than their adult counterparts. Their bodies and minds change in ways that their peers couldn’t even begin to comprehend. When subjected to the unjust abuse, the cradled are no longer cradled in love and showered in kisses, but rather they become cradled in fear and silence. The sponges continue to soak up the interactions of their surroundings just as they were made to do, but they also teach a thing or two to anyone who will listen- so take the time to listen. The becoming become someone different, because of the demands that illness places on their weary bodies and delicate minds. And the enigmas, especially those additionally complicated by mental health illness, are even farther from being understood than the enigmas without health concerns. Kids, the future, the vulnerable, the capable, they will forever be on the roster for illness, because as I said before disease has no prejudice, and for this reason, all of society should practice compassion, take time to listen and be a paradigm worth imitating.

Sevy's Guide to Nothing: A Textbook of the Unknown and a Compilation of Their Stories

I wouldn’t say I’m predictable, but there are many things about me that I know for certain. I really despise ironing and my dryer is too far to throw clothes into for some unwrinkling, so I turn on the iron only to roll over the most wrinkled part of the outfit and then I stop. I’m not tough enough to drink black coffee, so instead I use the sweet creamer and lots of sugar. There are simple things in life that make me overly excited like the smell of freshly cut grass, cruising my bike even for short distances, and sleeping in flannel pajamas. Being alone is refreshing. My car is a safe haven, it inspires me to sing at the top of my lungs and cry when I need to experience the relief that tears bring. I pass in the right lane… frequently. I post pictures of my vegetables on facebook like people post pictures of their pets. And finally, I was made to be a doctor.

The clinic- To many it is a building to receive medical care, to draw blood and get medications, to receive new diagnosis, and to develop plans for your healthcare. The clinic is many things to many people, each with different expectations, but each wanting the same outcome- una vida saludable- whether or not the desire or resources are available to achieve such a daunting task. To me the clinic is the people. It is a building of people, for people and by people. It reminds me of a woman who meandered in and out of the clinic purely for social reasons. For her it was a place to stop by and exchange greetings, update the nurses on the upbringing of grandchildren, and of course metotiar about her son’s new girlfriend. The clinic- a place I’ve grown fond of and a place where I have witnessed life, but also a place where I was repeatedly challenged with the reality that life does not follow a textbook and up until now that’s all I’ve ever studied. 

The bittersweet lives of pregnant teens, the dichotomized lives of Cubanos who willingly forgot their home country and Cubanos who would return in a heat beat, the dangerous lives of the cleaning ladies in hotels across Central Avenue, the defeated lives of Vietnamese mathematicians who can no longer teach because they do not know the language so they suffice by painting nails, and the weary lives of viejitas and their husbands. Their stories have all been chapters in my life’s storybook, or rather my very own textbook, a textbook that continues to teach me how to be a better doctor, a textbook where I will never depend on finding the answer because of the individuality each case brings. But it’s a textbook I’ll continue to develop nonetheless.

In southeast Albuquerque, there lies a clinic, which is the medical home to generations of families and cultures from around the world. It wasn’t an ordinary day if I hadn’t worked with a Vietnamese or African language interpreter or relied on my very own and ever-improving Spanish speaking skills. The walls of the hall are decorated with portraits of Albuquerque families representing a smorgasbord of countries and unique familial compositions. My welcome into a diversity like none I had ever known began in this clinic, and I embraced every minute of it. The Latinos made up a large majority of my patients- this somewhat generic term incorporates the Cubanos who talked my ears off and the Mejicanos who felt like family, and ranged to just about every other Latin American country. The Vietnamese population contributed to a big bulk of the clinic, and with each interaction I bravely dove into a culture I knew absolutely nothing about. Intermingled throughout the day’s schedule were individuals from Thailand, Congo, Kenya, Pakistan, Iraq and more.  The globe, a once massive and incomprehensible structure, was slowly becoming smaller in my eyes as I witnessed the unifying abilities of medicine. And, of course, the burqueno locals, made up the remainder of patients.

CHAPTER 1: Sacrifices

I entered the room only to be engulfed in the smell of lingering smoke and the presence of a Cubano in his 60s. He wore what looked like every piece of gold jewelry he owned on his fingers, wrist and neck. His button-up shirt was unbuttoned to the 4^th or 5^th button and he held his walking cane loosely between his legs, which were covered with long socks and sandals. He didn’t speak a word of English and his Spanish was more rapid than that of an auctioneer. The ends of certain words were abruptly dropped and he quickly embellished his expressions with hand movements twirling back and forth and up and down. His wife, a pleasantly plump lady, and her grandson accompanied him, but spoke minimally. They had brought along a gift for the doctor’s daughter, who they had remembered recently celebrated a birthday. El Cubano Loco had begun each sentence with “Doctora” despite me telling him I was merely a student, and he completed each sentence with a facial expression to match his recent statement. He went on about how his wife wanted to dance and how his worsening back pain had prevented him from accomplishing such a task. He told me how Albuquerque has been his home since the moment he stepped off the plane from Cuba in the 70s, and how his wife has been back to visit but he refuses. I was happy to share my home with this family, but saddened that his wife had to sacrifice the comforts that only Cuba could offer. As he sauntered on about his home country, I couldn’t help but let my imagination wander. I suppose I’ve seen too many movies, because I was inappropriately being stereotypical, as I let my mind create a history for this man I had met only once. In my story, I imagined him escaping a criminal life as a head honcho never to return to Cuba for fear of relapse or worse- retaliation.

My other Cubano favorito, which I remember with fondness because he complimented my Spanish accent, was a middle-aged man with a bad case of the sweet-tooth. He had two of the worst diagnoses as far as diet are concerned, and this nearly brought the man to his knees begging for a break or better yet a cure, none of which I could offer. He had gout preventing him from consuming meats and alcoholic beverages and he had Diabetes, which we know limits ingestion of all the simple pleasures in life. He had told me there was nothing left in the world that he could eat, and a sense of sorrow beamed through his facial expressions, a look I had never seen associated to something as relatively miniscule as food and I love food. He then lost connection to reality and his Cuban Spanish, as quick as a gushing fountain, began to list off the types of oranges from Cuba, the sweet, the bitter, and the in between. I didn’t realize mouth-watering could be so contagious. I let him enumerate his fruits like Bubba when he listed of the different types of shrimp to Forrest Gump. When I asked him what he eats in an average day, he surprised me by telling me his daily breakfast consisted of drinking a can of condensed milk. The thought was so sweet I nearly got a tummy ache just listening to it. I left that interaction feeling hungry and somewhat defeated that this man’s pleasures in life were stolen from him and recognized the sacrifices we must pay for health. 

Textbooks tell me to treat Diabetes with low sugar diets.

Life tells me that the simple pleasures keep you happy, and without happiness life is not pleasurable.

Lesson- I will meet my patients in the middle.

CHAPTER 2: The Power of Prayer, The Power of Tears 

My beautiful grammita passed away during my family medicine rotation, so when my 85 year old patient broke down into tears because she missed her grandkids so much, I couldn’t help but let the tears stream down my face. She was your typical grandma; she kept all her annual appointments and had been coming to the same doctor for years. She went to church on Sundays and sometimes Wednesdays, and she knitted little matching hats and dresses for every little girl she knew even if only remotely. She prayed for her children daily and even lit a candle and said a few rosaries when times got tough. But when I reminded her that she had to schedule an appointment with the cardiologist to follow-up on her heart condition- her strong and happy-go-lucky mentality melted into a story that quickly lodged old memories into the front of my mind. By this time my supervising doctor had joined me, and unbeknownst to me she had also recently lost her grandmother. My little grammita patient began to tell me of her son's recent divorce and how her ex-daughter-in-law had taken the kids. She was spending her days praying. Praying first thing in the morning, praying before meals, praying before novelas, praying at bedtime. She was on a praying binge.She had went from seeing them daily to sparingly, and she was consumed with heartbreak.  I was reminded of the tormenting few years when I first moved away from the brick house that sat cozily next to my grandparents’ home, in which I could easily trot down the sidewalk for a quick visit, some cookies from the endless supply in the cookie jar and peas from the garden. My grandma would inevitably be making dish towels or rolling tortillas with ease. The three of us sat there in tears, and together we reminisced of the past, we held tighter to the memories and we put medicine aside for a much needed moment of tears. It was a reminder that grandmas make the world a beautiful place and that healing comes in all shapes and sizes. Healing is not only distributed in a pill form, but also with the release of tears and the invaluable moments of conversation. I am thankful for the endless nights of prayer that many wise women in my family have devoted their time to. Rest in peace Leonor Gurule.

Textbooks list the stages of grief and use words to describe the indescribable process.

Life has taught me that grieving can begin in a clinic room with strangers and that medical care gets in the way of times for grandmothers to pray.

Lesson- Grieve and encourage grief, it may take years but you’ll be happy you did.

CHAPTER 3: Addiction vs. Coping: Only One Will Win
 

The clinic has many sub-clinics, if you will, within it and one is devoted to the care of pregnant women who also happen to be addicted to drugs, often prescription pills. It’s associated with a home where these women live and grow together. They often become inseparable friends throughout this time and face their challenges as a team. While working in this clinic one Friday morning, I was surprised by the women I saw. I must admit, embarrassingly so, that I had some preconceptions on how that day would unfold and I was pleasantly wrong. The first young lady that I saw was a beautiful and bubbly woman, who was due any day. She had a list of questions to be answered and a good fifteen minutes worth of pregnant yoga shenanigans to divulge. We chatted away and quickly bonded, despite being previously advised to not be offended if the patient didn’t open up, because these women tend to be attached to their doctors. She readily told me how she was really busy making plans for her baby, who would be taken by her sister after delivery because she was leaving to prison for robbery and illegal possession of a weapon. She wore sorrow and embarrassment on her face, but the gravity of her circumstances didn’t penetrate the bubbly girl that she was. I recognized in her eyes that she knew she was paying the consequences for her actions, and she learned a lesson far greater than any. She also shared her troubles regarding the program, as she was torn between the rehabilitation opportunities and spending time with her visiting son, who had come from the west coast. The program denied her request to leave for a bit to stay with him and he couldn’t stay in the house, so she was tossing around the idea of leaving but fear kept her from once again entering a life where she could easily access the poison that had put her in this situation in the first place. Somehow all my problems seemed so benign. The final woman that I had the privilege of working with was pregnant with her first child, something that caused her to ooze with excitement. I also immediately sensed some mania-like characteristics upon entering the room; She was quite the talker and chatted away about any and every thing. She caught me up on drama in the house and I couldn’t help but imagine her life was like an episode in Jersey Shore. Her update ended with a story of one of the other girl’s in the house and her brave attempts to prevent relapse. The other girl was also pregnant and lost the baby shortly after it was born. All the women in the program attended the funeral and at the end, this young patient thought it best to follow the grieving mother and sadly her suspicions were true. My patient had followed the girl out behind the church only to stumble upon a drug deal. The mother who had just lost her day old baby was returning to her old coping mechanisms, which sadly is not coping at all. Drugs are a method of blunting emotion and removing oneself from reality only to ignore the unwanted truth. It was a solution far from ideal, but a solution so natural to her. My young patient sobbed and I silently sat there remembering the lives I’ve seen destroyed by drugs. I felt defeated once again by the power I would never cease, the power to cure addiction, a power I have always desired to wield, but one that is non-existing. 

Textbooks offer an array of anti-abuse medications, and attempts to perform motivational interviewing.

Life has taught me otherwise, addiction is pervasive and follows no rules. As an outsider looking in you will be helpless and you will be angry, but somewhere behind that mask of drug-addicted bewilderment is a person who depends on you.  

Lesson: The power to yield change will never be as simple as the book teaches. Try anyway.

CHAPTER 4: Cleaning Just Got Messy

The old cleaning lady who spends the majority of her life on her knees and feet cleaning up after people had a face warped with deep crevices haphazardly strewn about. She appeared much older than her stated age, but she had the energy of young woman. She was bold and eagerly shared her torments of being a cleaning lady for hotels along Central. She had told me about the various dead bodies she had discovered and the eerily unique positions she had found these once living people. She was jaded to the subject and I knew that my own career would be one filled with death, but one augmented by the technologies of medicine. My eyes were opened to the realities that our patient’s face, the darkness that fills their lives, and the things I could never comprehend. I had hundreds of hours of lecture and not a single one would prepare to counsel a woman who saw the things this lady saw. If I reached back into the most distant of memories, I could not recall that lecture entitled "The Struggles of  a Housekeeper on Central Ave." Ill prepared? Possibly, but surely the medical school curriculum committee could not have anticipated such a scenario.

Textbooks are invaluable sources of knowledge.

Lives have infinite opportunities for exploration, leading to infinite opportunities for distinct outcomes. I could teach you for centuries and you would still be untrained for the challenges of your patients.

Lesson- Learn every day, because you will never know enough.

All in all I met mothers and fathers, their children, the grandparents, the lone rangers and the lost. I had been asked in a psychotic tone what a Diabetic coma felt like, and I had to tell a young Vietnamese boy that his exam was worryingly abnormal. I had a grown man cry like a child when I tried to discuss with him the importance of keeping his Diabetes under control, and his wife aggravated the situation by forcefully reminding him that she could not raise the entire family on her own if something were to happen to him. He told me he felt like he had cancer and it was the first time I realized the seriousness of a Diabetes diagnosis for a family in near poverty. I counseled a young woman who had just lost her best friend and warned her that that void would never be filled, but that our loved ones leave with the hope that we will not die with them. I shared tears with her when I told her of my very own losses. In the end, my textbook is filled with the lessons of life. It is malleable. It has to be. And it comes with a giant sized eraser and sticky notes. There’s room for impromptu additions and the pages are durable enough to endure sketches that have been erased and redone. My patient’s don’t read the textbook, so of course they cannot follow it. So my textbook allows for mistakes and creativity alike. It is a textbook of reason and not one of rule, it is a textbook of suggestions and not one of guidelines, and finally it is a textbook with lessons to learn from lives already lived.

From a cabin, to the maple trees of Vermont, and finally to the heroin addicts of Albuquerque, I journey through medicine.

A thriving infant swiftly, within just over a years time, transitions from being comfortably cradled in his mothers arms, to exploring the wonders of the floor world, to finally ambulating independently on two feet. With each transition, there is often a period of time in which the infant familiarizes himself with new muscles. He inevitably outstretches his arms and legs and learns new ways to move them. He builds strength, as he unknowingly exercises them with every movement. And he grows with the nurturing milk of his mother. I've recently witnessed my favorite little man, Noley Posole (as I call him) complete this process. He currently waddles from room to room, across vasts patches of grass, between the legs of his cooking mother, and even climbs down from the couch with ease.

My first two years of medical school were much like the stage of being cradled. We were only accountable for ourselves, we were given lectures and tests in which we reproduced the information, and we were guided through physical exam maneuvers with hired patients, who were virtually healthy. We basically had no real responsibility (surely at the time it didn't feel this way, but looking back it wasn't all that bad.)

Following this we 'graduated' from the classroom after taking one of the most important tests of our lives: USMLE (United States Medical Licensing Exam) Step 1 exam, or as it is informally called 'the boards' or 'the step.' This exam is a measurement of our knowledge in all the fundamentals of science, behavioral sciences, and so much more. The score has the ability to determine your future, as it gives residency programs a baseline score to compare you to other students across the nation. You have no other option, but to pass it if you want to continue your medical education and become a doctor. In an attempt to prepare for this oh-so-important test, I locked myself in a beautiful 3 bedroom cabin in the middle of the Pecos wilderness, surrounded by a peacefully flowing river, towering pine trees, and on many days blankets of white snow and sheets of ice. It was for six weeks my little piece of heaven, which I shared with my little sister's dog Oreo. While I didn't take too much advantage of the breath-taking outdoors, I did use the never ending peace and quiet to focus on studying. I stuck to a ridiculously stringent routine of awakening by 7 to make coffee, having breakfast, and listening to a recorded lecture by the all-knowing Dr. Goljian and by 8am I was already hitting the flash cards and books. I studied nonstop from essentially 8am until at least 8pm, if not 10pm on days where my energy reserves permitted. Of course, I allotted time to lunch and dinner and even an hour for exercise (which changed to an hour of napping, when times got rough). I studied six days a week, with the exception of one 4 day weekend to San Diego to see little sis get hitched. It was absolutely the longest studying binge I had ever had and by far the most self-discipline I have ever had to endure. There were times when I thought I was losing my mind and times when my mind would completely shutdown and I'd have to read sentences repeatedly before absorbing the information... yet, I persevered. In complete devotion, I even gave up my social networking addiction and my cell phone was completely disabled... determined to get an excellent score or completely insane? I have yet to decide. This preparation was much like the in-between period before learning to walk. It was a time to explore the world completely stabilized by four limbs instead of two... a time to test your true understanding of concepts and a time to reinforce concepts that were weak.It was a time to test your endurance and will to succeed, and finally a time to test yourself. We were learning to crawl and explore the "floor world" of medicine as an infant does before it dares to walk on two feet. It was a time that won't even be a blur in our future.

Following that dreadful six weeks of frustration; fatigue; endless sample questions; reading my prep book three times from cover to cover; and another book through and through once; and listening to lectures on my computer while exercising, cooking, cleaning, and even getting ready at times; I took that nearly 8 hour exam....

and PASSED with a pleasingly high score!




Following this six weeks of seclusion and brain-saturating days, I left the country for a much needed break and returned for a four week transition course that would prepare (or rather attempt to prepare) us for the year to come: Clerkships, a time to rotate through various specialties of medicine and a time to see what being a doctor is all about. This four week course was also a time to recuperate and get as much socializing and sleep in as possible, although this proved to be tough with endless research deadlines (which I might add is proving to be a nice breakthrough in the public health arena), planning the annual School of Medicine Ball with only two other ladies, helping organize the Hippo Awards (which is essentially an event to honor our favorite professors and perform skits that remind us of our first two years of med school), and so much more! I guess you could say we never really rest as med students.

And then literally one weekend of freedom later, we were thrown (kicking and screaming) into hospitals and clinics across town. We we're now entering the stage of infancy where we would learn to walk, whether or not we were ready. We would be lifted from our bodies that had only recently mastered crawling and we would be launched forward into the next stage of development. The class I had spent hours with day after day for the last two years was separated abruptly never to be reunited... Little did I realize that our only interactions would be passing each other in the hallways as we swiftly march to patient rooms only to ask quickly "what rotation are you on" and after receiving an often anticipated answer, you march back off to the task only slightly remembering the words of your peer.There's always too much on the mind to fully hear anything... to much on the mind to think, yet were in positions where thinking is absolutely vital, absolutely required.

The wards are a different world. The language is different and I am slowly learning it. We speak in acronyms most of the time and we type in code. For example, the first line of one of my notes might look something like this:
"Mr. J. is a 55 yo male with pmh of HTN, CHF and CKD who p/w SOB X2 days and denies chest pain, n/v/d/c, f/c."
Translation??
Mr. J is a 55 year old male with a past medical history of hypertension, chronic heart failure, chronic kidney disease who presents with shortness of breathe for two days and denies chest pain, nausea, vomiting, diarrhea, constipation, fever and chills."
It's a language that no one really teaches you, but expects you to know. Sometimes when I'm in the midst of conversation with a group of docs regarding a patient, I wonder what an outsider looking in would think... They'd probably think we were making crap up, babbling like idiots! Sometimes, actually many times, I have to scribble down acronyms to remind myself to look them up later. Let's just say this learning curve is rather steep... in fact it wouldn't be far from the truth to describe it as a learning cliff.

The hospital is a place like none I've ever known. I am surrounded by sorrow and sickness. And on the mornings when I arrive before the sun is only preparing to light my walk from the parking lot to the hospital, I walk through halls that are easily described as eerie.  Faces turn to look at you more slowly and shuffling feet in the hallway penetrate the quietude. The nurses move like molasses at the end of their long night shifts and the overnight docs blankly sit in front of their computers typing as if doing so automatically. The cough of a common cold sounds more like a TB patient hacking up a lung and the moans and groans of the lady in room 306 sound just like the llorona lady your grandmother always scared you about. And while it's not a pleasant place, I often found peace and comfort in knowing that my ill and often dying patients were sleeping and resting their weary and worried minds. I found peace in knowing that they had survived the night. I found peace, a very unusual peace, in the stillness and the slowness of those early mornings.

There is hierarchy in the hospital, a very very prominent hierarchy that you would be foolish to lose track of. Every team of doctors.... and me.... is named after a color. At the U (the shortened and more used version of UNM), I was on the gray team- a rather boring color, which did not accurately portray the not-so-boring experience I had; and at the VA I was on the yellow team. You spend your entire day with the team, you meet up in the morning and triage, you round on each patient, you sit and write notes together, you go to meetings together, and you even sit in the physician work room exhausted as can be, but cheerfully jamming out to Tom Petty and eating junk food that the intern bought with his stipend money. You spend nearly every waking hour with your team. More or less, each team is comprised of an attending (the jefe of jefes), then the resident (a young doc who is about 2-3 years post medical school), then the intern (fresh outta med school), the sub-intern (a fourth year medical student, with exponentially more responsibilities than the measly med student) and finally there's me- the bottom of the totem pole... literally as low as you can go.  My team changes on a regular basis as docs switch between teams, or from one service to another, or they graduate and move on. My last team was incredible- my attending was a middle-aged German woman who had stories from abroad as she doctored around the world and she's known for buying a dying patient some barbecue sauce to douse their last meals with; my resident was a devoted Latina woman who is invested in the care of each and every patient and who advocates for their care in an admirable way; my interns (I have two) are incredibly rambunctious and helpful young adults who take the time to teach me a thing or two every spare moment we have (which isn't too often unfortunately). In a matter of 5 weeks, I've worked with so many doctors- an intern who literally took an hour out of his busy schedule to read through my plans and provide feedback; a sub-I who I felt so comfortable with I could as the dumbest of questions; and my very first resident who waddled around pregnant as could be, but working until the very day she delivered. All in all, I was delving into a world of doctors of all shapes and sizes, with bedside manner and without, with foreign accents and with country twang, with absurd talents and dull as can be, with a never-ending passion for their job and a regret for not having gone to pharmacy school instead, with old-school training and straight off the printing press. It was a world I would slowly progress through and each year become closer and closer to achieving the title "Attending." I am in the midst of medicine, an imperfect and continuously evolving science that sooner or later I would be expected to have command over.I am in the midst of growth.

While I couldn't do anything without an incredible team, it was the patients that kept me driving forward... It was the patients who brought the purest of smiles to my face and the most sorrowful of tears to my eyes. They're the ones with the incredible stories... the ones that hang around in my thoughts from sun up to sun down.

She was a young woman, not much younger than me, but she thought she was invincible... she thought the world couldn't hand her a problem she hadn't already seen. She was indestructible, but completely destructed and she didn't take the time to accept it. Each time I met with her I lost a little hope no matter how tightly I attempted to grasp it. She was on my mind nearly every minute of every day... Our stories first intersected one day while I was on call and was sent to the Emergency Department to interview a patient who had overdosed. That was the only description I got for what I later would learn was an absolute train wreck.

He was an old cowboy from the mountains of Eagles Nest, an outdoorsey kinda guy who was tall and strongly built. A man with uncontrollable blood pressures and a diseased aorta, but a man I grew fondly of instantly. He was merely a consult patient, which means he's under the care of a whole different group of doctors, but we just make a quick visit to make sure a specific problem is being managed appropriately. It was the first and last time I would ever see him, yet his stories still weave their strings through my memory bank. He told me about knowing all the police officers in town and never getting a speeding tickets, he told me about the time his aorta burst and he was on the brink of death when a young stranger saved his life, he told me about his children and the strong relationship he had with each of them, he told me about his life as an entrepreneur and the family business that continues to prosper and finally he told me about a very special Christmas dinner with his grandkids. It was the first dinner he would host at his house after the death of his long time wife and the mother of his children. He told me about prior Christmases when his wife would wrap multiple gifts for each grandchild and how eager they were to visit for the holidays. But on that particular Christmas, the first since his wife's death, he chose not to purchase any gifts. At this point in the story, tears streamed down his face and the box of kleenex was securely tucked under his arm as he said he thought that if he didn't buy gifts, his grandchildren would remember to miss his wife. He was engulfed in worry that they would grow up and forget her. It terrified him, so he purposefully deprived them of a tradition that they had likely always taken advantage of in hope that their grandmother's memory would live on. I thought about my very own grandparents... and a bitter flow of sadness rushed through my entire body, made my eyes water and my stomach upset.

Upon entering the room in the Emergency Department of my overdosed patient, I was surprised by a slightly overweight dark skinned girl with what looked like large boils from being burned on the side of her face and down the side of her body. She was unresponsive to my questions and upon rubbing her sternum vigourously she was only mildly irritated by the painful stimuli. She moaned and groaned like a big bear, but could not articulate words. Her story for showing up here at the emergency department was a fragmented one from her worried mother and grandmother. But it was the test that the ER docs ran that provided a slightly different story- the tox screen from her urine showed more than 7 different types of drugs, her physical exam revealed track marks up and down her arms where she undoubtedly introduced her poison of choice, and her vital signs showed that her most likely diagnosis was overdose. Unable to get a complete story and unsure of what to do I returned to the on call room where I reunited with my team. Their only suggestion was to wait. So I did just that.

She was the first and last female patient I would have at the VA medical center, and I was the last student that she would interact with during her hospital stay. She was an elderly woman with a fairly advanced stage of dementia who was admitted after suffering a devastating heart attack that the staff at her nursing home thought was merely a bad urinary tract infection. Despite her poor medical condition, she often smiled and exhibited her very aloof and forgetful state of mind. She would lie peacefully in bed and each day she would decline in health a little bit more. She awaited the arrival of her well accomplished doctor son and his wife from the east coast. One day, early in the week, I  entered her room the same as every other morning. I asked the same questions to assess her mental status as I did every other day... but today her mood was energetic and her answers were lengthy and with each word spoken she shared a memory from what appeared to be a pleasant past and a happy life. As I was invited to enter her past, I felt a glimmer of hope that she was going to pull through this devastating hospital stay. She told me about her young adult life in Vermont and how much she missed the maple trees. She told me about a trip she had taken to Munich and how she loved it there. She painted pictures with her words about her adventures learning to ski and how it would become one of her favorite hobbies. And when her body was tired from telling her stories, she quietly slumped back into bed into her usual demented state and my attending and I meandered out of the room, down the hall, into the elevator and out the door on the first floor... only to recieve a phone call upon exiting the elevator that this lovely woman from Vermont who had traveled abroad had died a rapid and peaceful death. We retraced our steps to the room that we had been in just minutes ago and there she layed, already cold and already exuding the dull gray color that flushes over a dead body. We listened to her heart only to hear the post-mortem changes of blips and blops as blood dribbled among the non-pumping chambers of her heart. We listened to the lungs that would never again move air. She was dead only two hours before the arrival of her son's flight, and I'm glad that she didn't spend those last moments alone. I'm thankful that I could hear the last stream of consciousness that sprinkled through her mind. I was thankful for short period of time she had spent in my life.

"So did you intentionally overdose in an attempt to commit suicide," I asked her calmly as if it was a normal question of everyday conversation. In an angry tone she told me about how she had used a new heroin dealer and he must have given her something laced. And that was about all the story I muscled out of her for at least the first three days of her hospital stay. She couldn't tell me why she was found at the bottom of two flights of stairs in a mangled position practically cooking on the hot cement sidewalk. She couldn't tell me what had happened in the moments leading up to her overdose. So I continued to learn about her from the lab results I received- the positive hepatitis C she had likely acquired from sharing needles, the positive chlamydia test, the history of skin infections from injecting into her once untainted arms that I read about in her chart. Since she had fallen down two flights of stairs and had been found lying in the scorching heat for an unknown amount of time, her muscles had succumbed to a terrible disease process called rhabdomyolysis. Slowly but surely the strings of muscle fibers that made up her body were degrading and breaking down, and slowly but surely her kidneys were essentially becoming clogged. She was headed into renal failure and she could care less.

Another patient of mine, was a middle-aged immigrant from Europe. He presented with his teary-eyed and broken hearted wife, as she told his story because he refused to speak. She told us how a tumor had invaded his brain and was relentlessly entangling itself in his mind figuratively and literally. His thoughts had been jumbled and his personality, something we humans like to think belongs to us forever, something we can securely say we have control over, had been re-circuited and he succumbed to anger not only because of his circumstance but because of the precise location of the tumor. He avoided ye contact with his wife, who not only appeared fatigued and sorrowful, but terrified. His entire body had a tremor and he had no control over his strength, and could not perform simple tasks like touching his finger to his nose. He was a slave to his tumor, a tumor that would sooner or later take his life. I talked to him for a long while and attained his whole story. I had learned that the cancer docs had given up hope and how he had stubbornly refused to stop walking and kept falling. I had learned that he had immigrated to the US when his now adult children were young and that he had been healthy his whole life. And when I, like the cancer doctors, had nothing else to offer I asked him what food he most wanted to eat, I asked him if there was anything I could offer him to make him feel more comfortable. I wanted to offer him the world, but all I could offer was a special request to the cooks in the kitchen, I was even prepared to go out and buy a steak and lobster dinner for him.... but in a shaky voice he firmly provided a response that will always clearly remain in my thoughts, he said, "Make me a strong man again." My tool bag was empty and all the knowledge I had acquired until now had failed me, so I stood there completely helpless and on the verge of heartbreak.

 My patient who had overdosed on heroin was still in my care after a week. We'll call her Faith for confidentiality purposes. Her mother was always at her bedside and her grandparents visited sporadically and often at the most opportune times- like once when my patient adamantly refused to go to dialysis, her big Mexican grandpa talked some sense into her with a stern and concerned voice. Yup, my young-prime-of-her-life patient was on dialysis because her muscle breakdown has debilitated her kidneys to the point where they no longer functioned to make urine or clean the toxins from her system. When I told her about the severity of her illness, she looked me in the eye and with any sign of hesitance said, "I don't care, I've been through worse. You and your perfect life, you don't know me." I've never been one to have a temper, but I literally had to turn around and leave the room instantly. I wanted to shake some sense into her... better yet I just wanted to shake her. Every day before I left the hospital, I researched her problem, I looked for treatments. I developed detailed plans to treat her. I showed up extra early in the morning to review her labs and make any needed adjustments. I was working so hard, only to be repaid with worsening lab values and an immature attitudes towards my efforts. I was breaking little by little. The chipper med student I had set out to be was being torn apart from the inside out. 

Cancer was an unwelcomed guest that crept into the doors of many of my patient's lives, and one of these victims clearly stands out in my memory. He was an old hippie with a long white beard and stringy white hair that he messily tied high on his head. He wore glasses and talked about how he had hitched a ride from the west coast after struggling with a bad bout of constipation. He already knew he had colon cancer, but denied treatment about two years ago. Instead he returned to his nomadic life in the southwest. He hitch-hiked from state to state, lived on the street (because homeless shelters are full of "stinky people" as he noted) and ignored the symptoms that worsened each month. When he finally presented to us, he had admitted to not having a bowel movement in ages, feeling terribly bloated and having bad gas... symptoms that wouldn't be uncommon with a big bowl of beans, but given his history we knew we had to get a CT scan.... and what we found was astonishing. The cancer had taken up residence in his entire abdomen. It was even starting to creep into the muscles in his buttocks and posterior thigh. When the resident physician broke the news to him, she asked what we could do to make things comfortable for him. All he wanted was a warm glass of milk. He said while living on the streets, milk had always brought him comfort, maybe because he knew it had enough calories to last him a day in case food was scarce or maybe because milk is the drink of childhood. When we asked if we could call anyone, this grown and adventurous man, a man who had survived a life of living on streets surrounded by danger, cried. He cried and cried. He told us how he had never stayed in one place long enough to make friends. He said he didn't have a single soul who would care to hear of his news. The next day he had left in the middle of the night, after asking the hospital social worker for a bus ticket to Colorado- the place where he said he wanted to die, and a place free of Albuquerque bums and druggies (as he put it). I still wonder if he's alive roaming the cool mountains of Colorado enjoying the scenery, or if her died completely alone underneath a bridge somewhere. I wonder if he even made it to Colorado.

One week had passed and we were already nearing the end of the second week of Faith's stay. He kidneys still did not respond to dialysis and the nephrologists had even thrown around the diagnosis of End-Stage-Kidney-Disease... a diagnosis that would immediately qualify her for long term dialysis and a spot on the kidney transplant list. By this time her impudent spirit began to break. She had broken me and now she was on the verge of breaking herself. I entered her room early one morning and asked how she had done overnight, a question I asked every day and a question that usually got the response, "I'm trying to sleep!" But today she was already bright eyed and her mother wasn't at her bedside. She started to cry before a word even left her mouth. Her tears rolled down and I just sat there holding her hand and I let her cry. I didn't dare to break the streaming tears, the tears that were hopefully allowing reality to soak through. And when she stopped, I examined her and told her she could talk to me about anything. She nodded and I left the room. So while she didn't speak a single word, I felt peace in the interaction we had just shared and I didn't need any verbalization of the situation, I didn't need confirmation that she understood her prognosis, I didn't need promises that she would change her life. I just needed tears.

Many of my stories from the internal medicine rotation were sad- from grown men writhing in pain because of alcohol withdrawals so intense they cried like infants and brains that had been re-wired from years of alcoholism so that the individual told lies without hesitance. But in between there were also stories filled with joy, love and laughter. They were not few and far between. I had an incredible elderly couple, in which the wife didn't speak English and the husband didn't speak Spanish and when I asked about it they just giggled like school-aged children. I had a 90 year old patient who was spunky and healthy as can be. I had patients who bounced right back after treatment was started like a middle-aged quadriplegic who came in completely septic unable to vocalize his symptoms and within 24 hours was teasing the nurses and eating Chinese food his friend had brought. I saw success stories, I participated in cures, and I shared happiness with many patients. I was learning what it was like to be a doctor who sees one end of a spectrum to the complete opposite end.

 I left before Faith was discharged. I was transferred to the VA, but each day I pulled up her chart to see how she was doing... and each day her values began to normalize and her kidneys began to regain function. I was a little saddened by not being able to follow her through to the end and by not being able to witness the transformation, but I smiled nonetheless. I still think about her from time to time and I wonder if she's cleaned up her life. I must admit that I've logged in a few time to check up on her when I sit at the desk of my new clinic with some spare time. I quickly peruse her chart in hopes of finding something, but all I know is that she never showed up to any of her follow up appointments. Like the name I've given her, I'll continue to have faith that she'll come around. I'll have faith in the goodness of people and their willingness to survive, because without faith I have nothing else to offer my patients.  

Norway

I arrived in Norway late Monday evening and since then I have been in awe of the beauty of this place. Surely, the direct translation for Norway is the Land of all Things Beautiful. Norge, as it is called locally, is the country where the Vikings resided when they weren't out scavenging and causing a ruckus. It is also the place where true socialism exists and the government pays for everyone's healthcare, daycare and so much more. It is the home to many beautiful men and women alike (hypothesis for this- the vikings stole all the beautiful women during their raids and brought them back to Norway, so the gene pool is particularly good looking), and the country is filled with the greenest grass and the highest prices. My friend shared with me that it is the fifth most expensive city in the entire world, just behind another Norwegian city and a few from Japan. On that note, I am spending wisely and mostly cooking for myself or eating sandwiches. Likewise, I am avoiding public transportation and sticking to bike riding, which is truly a blessing in disguise.

Day 1:
My first full day in Norway involved a trip to the center of Stavanger (pronounced: Stavangah) atop an old and dirt covered mountain bike. All along the way I passed one house after another, each having a similar style, but varying in color, size, and yard, although most are white. In general, the houses are two story wooden homes built entirely of wood, in such a manner that the wooden panels either run vertically or horizontally throughout the entire house. All of the rooftops are steeply shaped to ensure that the rain runs swiftly down. The houses are encircled by perfectly manicured yards with green grass from all shades of green, hedges small and tall, massive trees, and often stone enclosures that have just enough moss to give everything a beautiful green tint rather than a slimy appearance. There are trees everywhere and bronze sculptures also dot the entirety of the city. From one mile to the next there are ponds scattered throughout city limits and they are pleasantly inhabited by large swans and many other types of birds. The church in the city center is a beautiful Episcopalian place and the rocks are also stained with a bit of moss. There are boats coming in and out from the sea bringing with them small waves and the sound of water crashing into the shore. Norway, like I said, is home to all things beautiful.

It has been cloudy and rainy since I arrived, but it does not keep me isolated to the dry confines of my room, but rather it offers a fresh breathe of air and I make sure to dress cozily.

In the afternoon, I accompanied my friend on a bike ride from Stavanger to a nearby village. This ride was breathtaking and not because my little legs were pumping the pedals for many miles, but because the landscape was absolutely incredible. We drove through small bike paths that ran on the outer edge of a beautiful lake surrounded by greenery. The rain was pouring hard, but I rode swiftly forward embracing every drop that moistened my clothes and dripped into my eyes. The roads were windy and hilly, but I peddled along between farmlands where the beautiful wooden houses offered a variation to the green surroundings. Norwegians, also unafraid of the weather, were jogging, pushing strollers, walking their enormous Clydesdale horses and dogs (even the breeds here are astonishing). We rode our bikes through farmlands that were lush and sparkled with fresh rain. And on the return ride, when it was slightly darker, but rain-less, there were greenhouses that glowed in the distance. The lights from the greenhouse shone brightly illuminating the vast and empty landscapes nearby. It was a real life Thomas Kinkade painting and there I was zooming though it on my little mountain bike. It was such an incredible sight and the pictures I took do not do the actual sight any justice.

Day 2:
Bright and early, my friend and I headed on our bikes to the city center where we caught one of the ferrys that travels between this city and Tau every half an hour. The ferry ride was about forty minutes of beautiful scenery. At first you could see the beautiful houses that lined the shore front and then there were large rocks that protruded through the nearly still waters. One of the rocks resembled a whale and for this reason, I have named it the Whale Island. I made sure to climb to the top of the ferry and venture into the outside (while all the Norwegians stayed warmly and dryly inside). Upon exiting the boat in Tau, I prepared myself for a 20km bike ride to the trailhead of Preikestolen (Or the Pulpit's Rock). The bike ride was sight after sight of breathtaking views. All the while we drove along the waterside and for a long while we were free from any sort of moisture. My eyes couldn't help but dart from side to side to enjoy the fresh waterfalls that pelted the ground beneath, the colorful houses that were constructed on either side of me, the enormous mountain sides that often crept up close to the road and were lined with large sheets of smooth rock, the animal herds that roamed around, and so much more. After the 20 km (the last 6 or so completely uphill) we began the 3 km hike to the top of our destination. The hike was the cherry on the top, as we jumped over rocks to avoid falling in the water that streamed beneath, carefully stepped on snow covered trails in hopes of placing our feet on the most sturdy patches of snow, climbed upward despite Seattle-like rain seeping through our 'water-proof' gear. We trekked on and I can without a doubt say that I have never felt so adventurous in my entire life! A trail that is often jam-packed with tourists now consisted of only the crazy and the brave (you can chose my label as you please). There was an older Norwegian couple and a couple from New Jersey that was visiting and that's it! But after the twenty min bike ride, the 40 min ferry ride, 20 km of mostly uphill pedaling, an arduous 3km hike, I made it to the Pulpit's Rock and boy was it completely worth every ounce of sweat! Even though the conditions were far from ideal and you couldn't see to the bottom of this massive cliff and the fjords were clouded over, I can say that I have witnessed this amazing natural site in these conditions... something most Norway tourists cannot. I screamed and heard the echos reverberate through the gorge, which would have been impossible if there were hundreds of tourists there to soak up my sound waves. I sang and skipped and took pictures solo on this rock that is often occupied by hundreds at a time. I ate some Norwegian dessert (the name has skipped my memory) in complete silence and I ventured out all the way to the edge on my hands and knees... and when I reached the furthest point out, my vision began to swirl and everything around me felt like it was tunneling around, like something straight out of the twilight, so I inched my way back to the safer part of the rock and regained a sturdy grasp.

All in all, Norway is a beautiful place and I have but two more days to explore. So until next time, goodbye.

Sevy Gurule- the self proclaimed extreme athlete :)

Sensing Life- Turkey (2)

The average day traveling in any country is filled with not only excitement and adventure, but an opportunity to revive senses that may have become accustomed to a relatively small level of arousal. A basal level of stimulation is experienced from a day to day basis, and for me the only way to heighten not only the frequency, but the amplitude of this stimulation is to travel. Traveling has never disappointed me when it comes to exposing all five of my senses (sound, smell, touch, taste, and sight) to novel stimulation. And for this reason, I crave travel.

1. SOUND

Sound is the sense that offers an opportunity to communicate in a verbal language, to sing in a native tongue, to express your love, and to even express anger. I consider the power of sound endless, and this is evident when you consider the fact that there are wavelengths that not even the human ear can absorb and interpret. There are variations in interpretations and there a preferences for specific sounds. Music and voice are beautiful gifts and for this reason I will begin with sound.

My journey through Istanbul has been a whirlwind exposure to culture galore. As I wander in the streets, sometimes with purpose and sometimes to purposely become lost (and of course found again), I listen to the people who surround me. I hear languages of all sorts, and many of the languages are the same but have different accents, or the gender offers a distinguishing factor. No one sounds the same. The language spoken here in Turkey is simply called Turkish and it is a rapid and flowing language. I have met many Turks on this incredible adventure, who thankfully speak English, and we have shared conversations galore. One convo occurred with the older gentleman who owns our hostel. This owner's name is Uner... Uner the owner :) One day over a freshly prepared and homemade meal in our hostel, we talked about the world. It was a beautiful conversation and one thing I will always remember is when he shared the following phrase, "You should be as comfortable in the world as you are in your own home." I will forever embrace these simple words. So in the end it was sound that has offered me an opportunity to learn from this country and its people.

2. SMELL

The sense of smell is incredibly intricate, so much so that it is only superficially studied in my medical school classes. I have a different smell attached to each country that I have visited and Turkey will be no different. Istanbul's Spice Bazaar, which is very long stretches of back-to-back stands in an indoor market is by far one of the most aromatic places I have ever visited. Each stand is slightly unique in it's display, character, and size; but, all have more or less the same contents. Upon entry, Des and I quickly wandered into a shop maintained by a son and his non-English-speaking father. The young man had quite the personality as he quickly spoke and smoothly dipped his great big spoons into tubs of spices and tea and gently held them up to our nose. One word: Heavenly. The Love Tea was beautifully colored with bits of roses, dried fruits, and leaves; the pomegranate tea was deeply red and smelled like pomegranate but because it was concentrated, the smell was overwhelmingly beautiful. There were spices for meat, chicken, lamb and fish dishes. They ranged in color from dark bluish greens to the brightest of orange. And each had a smell that could attract a crowd from miles away. My nose was happy to smell teas of orange, apple, and even rose. I smelled until my nose was no longer capable of differentiating one smell from the next. This happened to be quite a few Liras (Turkish currency) and hours later.

3. SIGHT

Sight is the most guaranteed sense to be stimulated. Sight is a glorious sense that allows us to see the wonders of the world, the most vibrant colors, the most beautiful faces, and the vastness of landscapes. Walking down the street is certain to entertain your sense of sight, and one of my favorite sights in Turkey was Topkapi Palace. This enormous structure, which defies architectural standards and houses some of the largest jewels in the world is a place of splendid-ness. The outside of the palace, on the day we visited, was surrounded by a thin fog that made it appear very Harry-Potter-esque. There were large trees and flowers encircling the perimeter and a huge gate in which you entered the building. Through the doors was a large courtyard where we noticed a unique tree which had split in the middle offering a clear view to the other side. We quickly stood in line to see the most beautiful place in the palace- the harim. The harim is the part of the palace where the sultan keeps his concubines- the women who he essentially uses to bear many many children. The harim was composed of tile upon tile, and as my friend Desirae explained, "There is detail on the detail on the detail." Each tile is hand-painted and they are arranged in nearly symmetrical patterns that display tulip flowers and other designs. The colors are vibrant, but I can't help but think of when the palace was being constructed and they were freshly painted. The entire length of the wall and ceilings are covered with tile and the floor is uniquely designed using small and various colors of river rock. The varying colored stones swirl about to create unique patterns and they offer an uneven trail to march upon. Upon entering each room, there is a small sign explaining the purpose of the room. Many of the rooms were merely for chit chat and entertaining and they were adorned with enormous fire places that all had unique shapes that domed as they neared the top of the room. They were large enough to fit both Des and myself. Many rooms had shelves that were carved into the walls and the doors of the palace were always intricately decorated with beautiful knobs. and knockers One of the rooms housed boxes large enough to display one woman, and this is where the sultan kept his favorite concubines. The room where the sultan slept had two larger-than-king-sized beds facing one another with tall golden posts at each corner. There were windows at the head of each one. I can't begin to fathom what this place looked like centuries ago when it was fully decorated with drapes and pillows and illuminated by candlelight. Following our journey through the harim, we entered the exhibits that lined the walls of the courtyard. Each one offered a new room of treasures and exposure to some of the world's oldest and most precious relics. My eyes were in awe of some of the things they saw. The first one we unsuspectingly entered was home to the Rod of Prophet Moses--- yes you read that correctly--- the grand rod that separated the Red Sea, that lead millions to freedom, and that allowed God to save his people. In a large inconspicuous glass case, a simple rod with only one small twig sticking out near the top proudly sat at about four feet high. It was darkly colored and lighter areas of tree marbeled it's way throughout the rod giving it a two tone appearance. I had to get back in line to see it again.... and again. I am blessed to have laid eyes on such simple beauty. While chatting with one of the guards, we asked why it is not highly advertised that such a precious gift is displayed here. He explained to us how Christians are practically enraged that Turkey has this relic and for this reason refuses to allow pictures to be taken of it and even souvenir museum books to print its picture. We also saw the bones of John the Baptist, the beard of the Prophet Muhammed, elegantly decorated turbans and wedding dress, diamond and ruby studded swords, boxes, thrones, etc. I think this place is worth billions of dollars.

4. TASTE

Taste has got to be one of the most pleasing senses to indulge. I am often guilty of over stimulating my sense of taste. This country has tested my limits of self control. Turkish delights are one of the little treasures that Turkey possess. They range in color and ingredients, but they are more or less gummy/jelly rolls filled with nuts and covered in powdered sugar or more nuts. My favorite is a beautiful pistachio one that has a hint of honey and is dipped in powdered sugar. I can eat them by the hand fulls. There are many Turkish Delight stores that line the streets and I often meander through just to get the free samples (sin verguenza). I can't seem to get enough of these little tastes of heaven, as they eagerly tempt me from their display in every other window case. There are a variety of other foods that send my taste buds shouting praises through the streets. I adore the taste of lamb in the many dishes that offer it (particularly the testi dish was cooked in a clay pot and cracked open before your eyes) and I fall head over heels for the juices filled with fresh squeezed oranges and pomegranates.

5. TOUCH

The fifth and final sense is touch- One that is scientifically proven to be a necessary sense for human development. In fact, neglected children who lack human contact fail to thrive and can even die if interaction does not ensue quickly. Touch is important for everything- it allows us to maintain our balance, differentiate between a silk scarf and a cotton one, it offers the ability to show love and compassion. Turkey is famous for its Turkish bath which exemplifies touch and its healing and soothing powers. The baths were surprisingly much much much different than what I expected, for those of you who I tried to explain them to scratch what I said because I was very wrong, but the surprise while at first very shocking was by far one of my favorite events in Turkey. It is a story of a bath without a bath. Upon entering a regular door in the string of restaurants, stores, etc, we encountered your typical counter where we were able to look at the various services offered. Desirae and I decided to get nearly everything. After all, when do you get to indulge in a Turkish bath... not often. So we were herded up a winding staircase and given a small plaid red towel where we were asked to undress and put on some black undies that were provided. We obliged and then were sent back down the staircase and into a room where we waited to be selected by one of the Turkish women. The women were wearing the same issued black underwear and that's it and many of them had breasts to their belly button. They walk around shamelessly and sweep/carry out all their tasks as if they're not completely naked. Then one of the women chooses you and escorts you into a circular room with a large circular stone in the middle. Then.... the woman, without warning, ripped my towel off and pointed at the stone for me to lie down with the ten or so women already relaxing. So there I was half naked, as my friend was similarly being escorted into the room, and so I lied face down on this very warm circular, grey stone. The warmth was thankfully comforting, and so I sat there staring at my friend with a very surprised look and we just burst out in laughter. When we realized our feet were hanging over the edge, we decided to scoot up and did so as little inch-worms trying to cover all of our bare surfaces. It was probably one of the most comical sights in the entire room. We couldn't believe this was actually happening. Here we were thousands of miles from home, in a traditional Turkish bath, surrounded by more than half naked women we didn't even know... and then it got worse. The older robust lady who had earlier escorted me into the room began pulling on my ankles, so I was laying down near the edge of the stone and she began to scrub me with a large rough scrubber in every crevice, and I mean every crevice. She washed my hair and covered my entire body in bubbles. She took time to rub my tired muscles and rinse me not-so-gently from head to toe. She dumped buckets of warm water over me and I could feel my body becoming softer with each scrub.... The soap was endless. She used a pillow case to squeeze soap suds all over my body and all the while I laid there on this round warm stone without ever saying a word. Following this I was once again escorted to a hot tub type of contraption in a very old stone room that I believe was built in the 1600s. Touch, a sense necessary for life, was now making every part of my body feel more alive and fresh. I was for the first time in my entire life comfortable with nudity and oddly okay that a woman was washing me while her breasts were swinging all about. This was not the end. From here I entered a room in which women were lined up preparing to do a full body massage and a head massage, which was where we had paid extra. So for over two hours, I was completely pampered in an odd Turkish sort of way, rather than in a typical spa where there's complete privacy and the massage is carefully draped and your therapists are completely clothed. It was an experience of a lifetime and I never want to bathe myself again.

So in the end, Turkey did not fail to stimulate every sense from all angles into the deepest corners of my soul. Turkey did not let me down and it will continue to hold a very special place in my heart.

A woman with an unknown identity,
I have been called: a Spaniard, Italian, Venezulan, Syrian, Arabic and even Turkish, but never American.