Tomorrow Brings a New White Coat

On June 4th, I packed up everything I own, somewhat aggressively stuffed it into my step-dad's trailer, and drove three states over in my new car to my new California home, where I would start my new job. Yikes! A whole lot of "news" in there.  The two day journey involved a caravan of vehicles, some great company (mom, step-dad, little sis, and Aaron), a night in Sin City, several tanks of gas, too much fast food, and lots of neat podcasts. My co-pilots were none other than the beautiful house plants that decorate my window sill and my snack of choice was a scrumptious bag of peppered beef jerky, thoughtfully bequeathed upon me by my future in-laws.

Of course, I was excited and happy to finally be on my way, but the emotion that overwhelmingly took the reins was anxiety. Somewhere around the end of January, I fondly remember sitting around a lit fireplace sharing wine and laughter with new friends from all over the world. Two people from the dozen of travel-crazed foreigners sharing our hostel were an Austrian couple who had taken some vacation time to hike the many volcanos in Ecuador's Cinturon de Fuego, or Belt of Fire. At one point the woman laughed uncontrollably, nearly forgetting to breathe, and then gasped as if she had been submerged under water for a record length of time. Her counterpart jokingly teased that she was allowed to laugh so uncontrollably only because she was surrounded by doctors. It took a couple seconds to realize they were talking about me, a couple hours to really realize they were talking about me, and a couple of weeks to get over the burden of their words. I was a med student then and graduation, even though only a few months away, felt like an eternity. Now... however... I am that doctor, a doctor, the doctor, somebody's doctor. I'm a doctor. Forgive me, I'm still trying to recover from my episode of hyperventilation.

So, tomorrow's the big day. I start residency in family medicine, where I will master the technique of delivering babies, taking care of sick children, working with adults to improve their health, comforting the elderly as they take their last breaths, and of course, becoming the doctor I've always dreamed of. Here I go, ready or not. I will begin this part of my journey alongisde 11 other eager interns. We meet in the beautiful, not so big city of Santa Rosa, in the midst of lush vinyeards, flowing rivers, and rolling hills. We come from all corners of the map, each bringing new perspectives and talents, each with a life story that will be slowly revealed over the next three years. I have already met these smiling faces for a quick potluck and I couldn't feel more honored to begin with such an enthusiastic and caring team.

Santa Rosa is nestled in Northern California, just 50 miles or so from San Francisco. It's a short drive to a beautiful beach, where the cold Pacific Ocean gently crashes onto a sandy shore. We've visited Jenner Beach, where the shore is outlined by a steep and often abruptly ending canyon decorated with flowers of all colors. On the way, we passed through several small towns. The two-laned road quickly goes from being surround by vast fields of green hills dotted with perfectly linear fields of grape vines or densely coated forest so thick you can't peer in very deeply to a two-laned road lined with the town's finest restaurants, antique stores, local jewelery merchants and more. We stopped at one point to enjoy a local brew, the World Cup game of the hour, and some fine pizza. We have also made the day trip to San Francisco and the nearby Muir Woods forest, which is home to massive Redwoods, ancient in age. The trees stand firmly in the their place and the deep red bark encircles the wide trunk, appearing somewhat like dark red wax that once warmly dripped down the side of a candle, now stuck for eternity. We have thankfully become lost in this very unfamiliar territory, only to be led to beautiful sights, large farms with hungry dairy cows, neighborhoods with enormous mansions, winding rounds in the midst of northern cali scenery, and lonely lakes nestled between uneven hills. It's been a treat to our New Mexico adjusted eyes.

Aaron and I have made ourselves at home near Santa Rosa's downtown. We're near the movie theatre, the mall, tons of tasty local cuisine, the famous Russian River Brewery, and so much more. Our apartment is completely unpacked, but the walls are still bare and the closet is in need of some rearranging. We are happy, eager, and in love. The adventures that await couldn't come soon enough. So until tomorrow, I will enjoy one last moment of drinking coffee without having to rush off to work, taking my time in the shower to sing out of tune, and not bothering to tame my messy hair. I toast to one last day of freedom.

Peppered Pupils An Evolving Species of Doctor

             “Man is descended from a hairy, tailed quadruped probably arboreal in its habits,” said the famous Charles Darwin. On the contrary, a medical student has descended from highly motivated, persistent, intellectually curious do-gooders. It takes a long shift on the internal medicine service to create the being Darwin referenced, hairy and crawling on all fours.

            The evolution of a medical student is a beautiful one, at least in retrospect. Just as the iconic photo, The March of Progress, depicts man growing taller, walking erect with a sense of confidence and professionalism, medical school causes a similar progression of growth and poise. The March of Progress shows man evolving over a period of 25 million years. Medical school on the other hand is only four years- four short years to devote to the roughest part of medical education and four short years to develop into that strong and confident doctor walking upright with pride. That was hardly fair.

            Somewhere around the second week of July (you think I’d have the date memorized or that it would be beautifully engraved on some silver frame, but no), I began the process of evolution. All I remember is that my summer had been cut short in the year 2010 and it was likely the last time I didn’t complain about the interruption, because I had waited for this day for so long. I started medical school along with one hundred equally eager students- we began the journey that we had spent at least the last two to four years polishing our resumes for. We walked onto north campus like a bunch of Neanderthals, bright-eyed, bushy-tailed with no grasp of the technical language, no sense of how to use the tools of medicine, and definitely no understanding of how to properly interact with our co-occurring species- the patient.

            Anatomy lab was a moment to reveal the weaknesses, which needed speedy improvement; a moment to embrace the beauties of the human body; and a moment to evolve even more rapidly than the peppered moth, which sprouted a pair of pure black wings, as opposed to black spots on a white base in order to camouflage more appropriately on the soot covered trees during the Industrial Revolution. This scientific phenomenon had defied the widely believed perception of evolutionary time, the idea that it is a painfully sluggish process that slowly progresses through multiple millenniums, dozens of successive generations. And there we were challenging the belief yet again.

            It took a class like Anatomy to serve as the point in which students evolve or lose everything. Do or die. Anatomy became our Industrial Revolution, our pollution gone haywire. The stress, the tests, the hours, the trials- they all forced an un-natural selection and so we began to become a rare species, doctors. We ever so slightly became more knowledgeable, but continued to hold a dangerously small amount of information. Much of these details later proved to be useless like the fact that the seemingly important bone, the hyoid, is the only bone not attached to another bone, yet a fact that’s fair game for Dr. E’s extra credit question. We learned everything then, because we had no idea what would be important now.  

            What took billions of years to evolve followed by nine months of in utero development, just over a dozen years to mature, and a lifetime to age and destroy had been laid out in ten weeks of lectures, learning groups, exam questions, lab sessions, tutorials, virtual microscopy, and study sessions. The beautifully intricate and perfectly created structure of the human body, as well as the story of its creation from an embryonic ball of nothing to carefully placed muscles, tendons, organs, and bones had been crammed into one ten week block. It wasn’t until after that rapid two and half months that I realized I had learned to think differently. I had more details to occupy my mind, more information, more perspective. I recognized how flawlessly each piece fits in its respective position. I tactilely confirmed it all- ran my fingers between muscles that once flexed and relaxed with perfect timing to allow for graceful movement and along arteries that at one time warmly coursed with supple red blood cells. I held organs in my hands, while examining every crevice and hole, memorizing their not-so-helpful eponyms. I had even taken a human brain and stared at it for what seemed like days in order to identify each thin and winding nerve, each sunken gyrus. Our peppered wings slowly became less peppered and slightly more solid. Just as the peppered moth refused to become prey to insectivorous birds among stained trees, we refused to lose this opportunity.

            I spent most of my time with Spike, a generous donor with a frail body and knobby knees. His naked and stiff body had initially been encased in a white plastic bag no different than the couple of dozen other ones that lay atop newly purchased steel tables with gutters to drain the spilled and oozing guts and goo (a word not adequately replaceable with medical jargon). He lied among many who had selflessly donated to this step in our growth as physicians and he was the first person, I’d like to thank for contributing to my education.

            Not only had anatomy made us intimately familiar with the human body, but we began to recognize that this vessel carries health and disease alike, emotionally, physically and mentally.  The object of our obsession had unveiled well and sick lungs. The normally marbled pinkish-purple lungs that were kept behind the protective rib cage sometimes exposed years of smoke exposure. I squished Spike’s relatively healthy lungs with a single gloved finger and they slowly and smoothly resumed their original shape, a testament to the lifetime purpose of inflating and deflating with ease, automatically and on command. Many of the blackish-purple lungs had lost their squishiness like an old, soiled, overused TempurPedic mattress. We witnessed the consumption of bodies by diseases we would later learn to prevent, diagnose, and treat. Spike’s abdominal cavity was infested with cancer. It was sobering as I stared into his belly and watched the cancer polyps adhere to any space sufficient enough for a pedunculated tail to anchor on to. The malignant globs of unorganized tissue lined the walls like bushels of small pale grapes with a hint of black, but these were deadly and poisonous grapes that were learning to out-evolve us.

            Aside from anatomy, we slowly dove into the basics of doctoring- this was the stuff we learned and still mostly cherish, unlike the hyoid bone. After hours in lecture and lab, we took additional courses that provided an introduction to the patient history and physical, or rather the irreplaceable means of attaining the necessary pieces to the puzzle. The H&P is equal to gold. It’s equivalent to the discovery of fire or the invention of the wheel, all tools that made life easier. And so a nugget at a time, we learned maneuver after maneuver, which questions we should rattle off like beers on draft, and tactical approaches to extracting the most sensitive of secrets.

            Darwin, a self-proclaimed workaholic, was also known for saying, “A man who dares to waste one hour of time has not discovered the value of life.” What he meant was “A man who dares to waste one hour not studying has not discovered success,” or at least that’s what it felt like for most of medical school. The learning curve had disobeyed the rules of a curve and had assumed the shape of a right angle. I spent at least a couple of hours studying every single day and triple on weekends. I relied on the company of my classmates, fellow study zombies who are also deserving an enormous thank you. The circumstance in which we selected for ourselves had caused a chain reaction of changes that led to our inevitable growth. The hours spent studying filled our brains with the information and mannerisms necessary to pass tests and move on. It’s like that expression: “When we long for a life without difficulties, remind us that oaks grow strong in contrary winds and diamonds are made under pressure.” We endured this to be what we came to be- successful.

            Following this whirlwind of a block, we continued through genetics, immunology, gastroenterology, nutrition, CV-pulm-renal, epidemiology, biostatistics, ethics, and every other necessary subject. The first two years were a whole lot of memorization, a whole lot of staged patient interactions with only brief splatters of flustered, anxiety-inducing real patient encounters, and a whole lot of tests.

            Not only had we learned to enjoy coffee for more than just the taste and aroma, we began to realize how all these carefully intertwined systems perfectly came together. The story, which had been painted onto a nearly blank canvas, had grown beautiful with color and some detail. It still looked like a blurred piece of art with areas smudged together and some spots unintentionally left bare only to beam brightly with nothingness, but nonetheless it was a picture, decently recognizable. We had become a unique breed of doctor impersonators, kind of like the stage where man sort of walked on two feet, but didn’t do it well. We were only 50% awkward with patients and our knowledge was there, but lacked any in-the-field-practice. We knew which medication to give for what disease, but god forbid someone asked about a dose, because those weren’t covered in lectures, the book or Step 1, for that matter.

            How could I forget? Step 1. That one enormous little obstacle that sat in our way of continuing the process of evolution. The step where you either act like a giraffe and grow a longer neck to eat the plump nutritious leaves at the top of the unevenly distributed tree, or you grow hungry, then weak, then die off, or move somewhere else where the trees are shorter-  usually not med school. My neck lengthened, most of ours did, some more than others, so we moved on to Phase II. The peppered moth evolved. It could have migrated away and occupied a more livable forest, but it chose to stay and change (maybe unconsciously, because who knows how much those little moth brains are capable of). We wanted to be doctors in the midst of change, so we also stuck around to also change. 

            There we were again, trekking up an unusually steep learning curve, fighting tooth and nail like aloof cave men trying to stay alive. We couldn’t possibly let the evolution train leave without us, because we had come so far and our loans had grown so big. So we devoted nearly all of our free time between the 60 hour work week to studying for the SHELF exams, which tie up the end of every block- internal medicine, family medicine, neurology, psychiatry, pediatrics, ob/gyn, and surgery. We moved along with the guidance of kind teachers, residents, attending, and mentors who are also deserving of our gratitude.

            Way back when, the evolution of man from some hairy quadruped to graceful, well-mannered, tool-using biped, involved the tripling of brain size. I’d like to think that our very own evolutionary process involved some tripling of brain size, or at least usable brain space, but our genetic information (with the exception of maybe those subtle changes in methylated DNA) had not actually changed so as to be inherited by our offspring (they might still be dumb, which totally negates my theory, so forget I mentioned it). But the information and the facts that flickered through our minds while encountering patients and their misfortune had tripled if not hundripled. We could actually think up doctor things and we often surprised ourselves.

            As newbies to every rotation, every case was a new case, even the routine ones. A patient with the common diagnosis of Diabetes could be our first Diabetic. And the second one would be so different from the first that it would be like another new case for us. We saw all these diseases from Robins Pathology book, but now they were attached to patients, their faces and their families. They were real stories and we slowly gained context, but we also learned that our patients weren’t cookie cutter examples like the books had taught.

            We learned the stages of grief in psych lectures, but we hadn’t learned to counsel the grieving grandmother whose ex-daughter-in-law divorced her son and took her two grandkids, which she babysat daily, half way across the county. This wasn’t a case where someone had actually died. We also learned how to conduct motivational interviewing and which addictions could be treated with anti-abuse medications, but what about the young narcotic-addicted pregnant woman who was getting ready to give birth only to begin her sentence in prison for illegal possession of weapons. The soon-to-be-mothers I worked with taught me more than any book. Addiction is pervasive and follows no rules and as an outsider looking in, we will be helpless and angry, but somewhere behind that mask of drug-addicted bewilderment is a person who depends on us.  The power to yield change will never be as simple as the book teaches, but as physicians we need to try anyway.

            The case that best demonstrated the novelty of our experiences was the old cleaning lady who spent life on her knees and feet cleaning up after people. Her face was 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 and 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 had prepared me 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 supposed to be invaluable sources of knowledge, and they can be. But lives have infinite opportunities for exploration, leading to infinite opportunities for distinct outcomes. We could go to a century worth of lectures and still be untrained for the challenges of patients. So in order to evolve into a doctor, we used these experiences as a lesson that learning should continue each and every day, because we will never know enough.

            Third year was a true test. We all went our separate ways, now strong enough to roam the open land, hunt and gather, or settle and cultivate. We could disperse freely into our rotations only to reunite on rare occasions. But we were all doing more or less the same thing- adapting for fear of becoming an obsolete species like Paranthropus which was included in The March of Progress, but later discovered to be “an evolutionary dead end,” not having led up to the creation of Homo sapiens. We adapted quickly, because we only had two months to learn each entirely new field of medicine, and only a day or two at most to get into the rhythm of the routine before it changed the next week or before a new team came on service or because it changed and no one thought to tell the med student.

            We were the med student, never really remembered for our given name because we came and went so quickly. We were expected to jump right into things when in reality everything was completely new. We were expected to excel in patient care and development of differential diagnoses, but we had no idea where to meet in the morning, or where to find information in the nebulous EMR. And there was rounds! There were times on rounds where I wished I could have fully camouflaged as nicely as those completely evolved peppered moths, because it could become terrifying… sometimes attending or chiefs wanted all the lab values, while some just wanted the abnormal values, some wanted just the plan, others wanted 60 seconds, some wanted the longer version, some wanted the whole physical exam to see what was done and others wanted pertinent negatives and positives. Despite being pulled in several different directions and despite continuously changing expectations, we not only survived, we evolved.

            I recall a moment after third year. It was our final year, so my schedule was much more accommodating of volunteer activities. I had signed up to work at the local homeless shelter and was paired with a first year medical student. Our second case was a hypomanic male, a veteran, or at least his fully camouflaged gear suggested that. He complained of a cough that had persisted for just over two weeks. The first year student had observed the first patient encounter, so I urged her to take the reins the second time around. She was awkward, flustered and had no natural flow to her physical exam, jumping from the mouth to the lungs and back to the head again. Her patient presentation also lacked a pattern. It was the pattern our very own evolution had engrained into our head- subjective, objective (always starting with vital signs, moving to the physical exam findings and ending with labs or other studies), assessment (a single sentence compiling the pertinent negatives and positives followed by a differential diagnosis), and a plan. Her differential diagnosis was a good array of guesses, but not in any particular order and with no detail. Pneumonia was pneumonia and her quizzical look when the attending asked “what type of pneumonia” proved that I had in fact evolved into a different species. My mind quickly scrolled with a more comprehensive differential for pneumonia. Viral was most common, secondary to strep pneumo, but the duration pointed to an atypical, perhaps mycobacterium. I stood there staring at a younger version of the being that leads up to our species. Lighter colors of peppered moths were still born for several years after the trees were soot colored. The two variations of species, typica and carbonaria, co-existed, as we did in this small makeshift clinic, as we would as long as the world needed doctors.

            After an adventurous third year, we were equivalent to the varying mockingbirds that inhabited the different Galapagos Islands. We had all started as a similar species but adapted to fit our niche.  We identified interests, gravitated towards our people, the people with shared personalities and goals. We decided if we liked little people or big people, women or men, cutting or talking, brains or bellies.

            Now here we are- all with striking differences, very different differences, but all graduating from the same school with the same degree. All walking on two feet. For now at least. It’s astonishing that we are the same creatures that share over 98% of our DNA with chimpanzees, and yet were being released into the world of medicine to observe, to unravel, to discover, and to conclude. We have all earned our beautiful, completely black wings, the ones that will make us more fit for survival in the field of medicine.

            It wasn’t a beautifully linear sequence of evolution so neatly depicted in the iconic picture, but if you squinted your eyes, it was beautiful. Many people met soulmates, best friends, future business partners, mentors. Through these relationships we can continue to measure the worth of this journey.

            “A moral being is one who is capable of reflecting on his past actions and their motives- of approving of some and disapproving of others,” again, words of the gifted mind of Darwin. From here, we will part, many of us to different parts of the countries and many will stay at our home school. And I hope that we will continue to evolve, continue to embrace the opportunity to change and grow. Homo sapiens is Latin for wise man. It can be such an undeserving title, but a title that captivates our potential. Evolve on, Class of 2014, and spread your beautiful black wings. You earned them.

Otavalo

We were in search one of South America's largest artisan market and what we found was a glorious opportunity to explore nature, meet fellow backpackers, and become so addicted to a place we had to tear ourselves from the comforts of Hostal Chasqui. After watching Bad Boys dubbed in Spanish, I was excited to emerge from the confines of yet another chicken bus. Otavalo is conveniently located just a hop, skip and a jump away from Quito and it serves as a central location for several hikes and nature tours. We started bright and early on Saturday morning, the day of my 27th birthday, in order to not miss the roaring animal market, where the hearing stimulus is comprised almost entirely of squealing pigs, stubborn calves digging their hooves into the dusty ground, and clucking chickens hanging from their claws unable to avoid their inevitable doom. Every 'bah' and 'moo' of all imaginable domesticated animals jumbles the air particles creating a roar of noise. If you don't attend early, your only sight of chaos will be silently sitting on your lunch plate. Makeshift collars are tied around every animal and baby chicks as squished into a small box peeping endlessly and trying to stay a float in the masses. There's kittens  and puppies being arranged cutely to entice the local children. The pigs are marched around like dogs on collars. Chickens are evident only when you realize what makes the dancing gunny sacks dance. The rest of the chickens hang upside down in the hands of a plump woman who's undoubtedly headed to her kitchen. It's chaos. It's defilement of animal rights to the greatest extreme, but more importantly it's an opportunity to see the locals in the midst of their everyday life.

The next stop just a few blocks away, across a busy intersection and over a small bridge is the artesan market. After all, our original and sole purpose was to empty our pockets  at this highly talked about local market. (Unbeknownst to us there was still a handful of natural treasures to entertain us.) The market stems from a central starting point in Plaza del Poncho and branches in every direction for several blocks. Each table is manned with a local person, sometimes a woman dressed in her traditional clothing, sometimes a man who exclaims his painstaking efforts  at constructing your sought after purchase, and sometimes a child. The market is colorful with hammocks swinging from every corner and sweaters with all sorts of patterns stringed along the back of stands. Every article of clothing is available in an alpaca material and often shirts are awkwardly sized with small arms and tiny neck holes. But the haggling and negotiating blossoms with every passing hour. My eyes always pan the area for tables of jewelry, my Achilles for sure. The jewelry is similar to the pieces I found in Peru. Turquoise, coral, and stones and shells of all colors make their way into a piece of jewelry. Even the extinct spondylus shell is proudly and sorrowfully on display. Many of the pieces are designed to be pleasing to the tourist eye, but many designs hold a more sacred cultural or indigenous symbolisms, an explanation the seller certainly uses to reel you in. Of course, after several trips of improving my creative attempts to cut down the price, I have never paid full price for a purchase. Haggling, a once intimidating task, has since turned into a fun opportunity to laugh and practice my Spanish with the locals. At the end of the day, my bag was much fuller and my pockets not as empty as I had anticipated. Great success.

Before the sun could bake us with its rays, we headed to the refreshing Peguche, a cascada (waterfall) only an hour walk from the city and quicker if the stray dogs make your heart pound as they did mine. Peguche is gorgeous and also happens to be the make out spot for local teenagers. We discovered this he hard way. We used the steep and crooked steps as an opportunity to get a daily workout in. And again before the sun could set, we hit one last market- the food market. This is where we found an array of veggies and fruits, many resembling fruits I know but clearly having some differences. We purchased all the necessary ingredients for a meal we would soon prepare in celebration of my birthday. Of course chips and guacamole were paired with some Chilean red wine and our soup, which we later called Otovalo Caldo, was sprinkled with the essence of our soul, powdered red chile smuggled into Ecuador by one Mr. Christian Garcia. It was a feast indeed. We cooked in our rooftop hostel kitchen alongside other eager traveling pairs, many speaking a language different than our own but all using English to share stories. And this is how I began my life as a 27 year old, traveling, shopping, eating, enjoying the delicacies of life.


Our final full day in Otovalo was spent on the go. After catching a bus to Quiroga, we then jumped  in the back of a small pickup truck with fellow backpackers for a twenty minute ride to Cuicoches trailhead. This is where we would walk the perimeter of an conveniently sized crater lake with two small volcanos peaking out of the water in the center. It was as if a moat had been created to protect these unique structures. This is where we would travel through varying landscapes after only walking a few steps. Initially we stopped every few feet to take yet another picture in an attempt to capture the beauty of this crater lake. The trail was steep but well kept and beautiful flowers lined it's way. We then ventured into a a more tight squeeze as the trail became a tiny walkway between to dirt walls. It forced single file walking and crouching slightly to fit. The dirt walls were moss covered and plants sat atop the dirt and fell in from both sides. The trail eventually began to slop downhill as we neared the second half of the walk around the perimeter. The last part, while not the best view of the lake since the clouds began to make its colors somewhat more dull was refreshing for another reason. The landscape had changed yet again, but this time to something right out of a photoshopped postcard from New Mexico. We were in the midst of evergreens, but these were different than the shy and bare pines of my mountains. They were full bodied and the needles so full of water they didn't poke as harshly. Don't get me wrong, I love our charming New Mexican pines. The trees were rooted in a fine grey sand and still we were a quarter of the way from completing the full circle. Finally after missing an unmarked turn taking the long route home, we finished the five hour exploration. I couldn't imagine Ecuador without happening upon good ole Laguna Cuicocha, named after the sound of a guinea pig cuiy, cuiy!! After this long but not so challenging hike, our hungry bodies were tempted into buy food straight from a street vendor, almost rule number one of something never to do in a foreign country. But we did and we indulged in humitas, which are a sweeter version of tamales because the surrounding dough tastes like cornbread. I had them once in Peru and it was a tasteful reminder of my South American adventures. They are filled with cheeses rather than the incredible red chile pork, but after a long day hike they're just what anyone needs. Speaking of food, posole is called mote here and it's identical to our dish, but the kernels are nearly twice the size.

Quito- Old Town

Old Town, it's like being in Spain all over again. All the colonial structures are huddled within a 1-2 mile radius. The churches are a spectacular sight and just when you think you've had enough, you encounter another. We started in Plaza Grande, home to palacio de gobierno y un catedral lindo. Just a few blocks away is La Iglesia de Santo Domingo, which is rather appealing given it's asymmetric appearance unlike the ornate churches with towers that mirror each other. La Iglesia de San Francisco was another sight not worth missing, and finally we were within arms reach of La Compañia. La Compañia is small compared to most of the other churches, but it's contents are beyond comparison. With tons and tons (and this is not an exaggerated statement) of gold plated walls, statues, alters and just about anything they could smother in gold, this place is a true treasure. In fact, the large room can make any healthy person appear a little jaundice secondary to the reflection of the tesoro (treasure). The yellow tint gleams in every corner and upon entry, you can't help but stand frozen for a moment to appreciate it. The walls are carefully sculpted so that not a single surface is liso (smooth). Gregorion Chant plays quietly in the background and there are several rooms that break off from the main one for further exploration. Mi parte favorito was La Basilica del Voto Nacional, quite the climb to the north end of old town, but worth the effort. The Basilica is likely the tallest structure making its views priceless, but also making its ascent frightful. And that my friends, is an understatement. The first opportunity to become fearful is walking the plank, or rather traversing a long sodden bridge that sits atop the meeting corners of the roof. The wood creaks and sways and all faces are focused. Then the first set of steps presents itself. It's a rusted ladder with narrow steps and grimy rails, but nonetheless you grip for dear life. Then the second set of steps is far worse and with each light breeze you recite a prayer silently in your mind. But then you've ascended and the view erases all memories of fear... That is until you have to make the even worse climb down. Quito from a bird's eye view is gorgeous. It's sprawls in a valley and even begins to encroach on the surrounding mountains. Churches and colorful multistory building are evident in every direction, but beyond the hustle and bustle of a city is towering green trees and a soft unobscuring view of the clouds. Panecillo is in the distance, where an angel is shackled to the ground by a snake. Quito, home to elaborate constructions of Catholicism, home to a rich culture with indigenous presence, and a place where I first enjoyed encebollado (or delicious fish soup).

Puerto Lopez

Boobies!! Blue Footed Boobies that is... And the stars of Puerto Lopez, the reason we hopped on a chicken bus for nearly five hours albeit it only $4.10. Within the hour of arrival, we were already taken captives by the beautiful blue ocean, the vast expanse of sand and of course the surrounding mountains. We walked along the beaches, knee deep into the waters and plopped into hammocks for the majority of the day. The hammocks are glorious- colors of the rainbow weaves tightly into large blankets and often secured on trees or sides of walls. Our night ended with a 2 mile jog beachside.

Day 2, however, was the highlight of this tiny beach town. We embarked Explora, the vessel which would introduce us to La Isla del Plata (Silver Island) after a fresh 45 km ride. Isla del Plata juts out of the empty waters and assumes the shape of a jagged mountain surrounded by enormous rocks and only minimal vegetation. The hike was short and sweet offering several priceless Bluefooted Boobie Spottings. These spectacular medium sized birds do not flee at the sight of humans but rather peer up curiously. The first sighting included a mother with her snow colored baby tightly entangled near her body. Baby patas azules (blue feet) are born completely white and gain their color as they age. They transform into grey, black and white birds with bright blue feet resembling large flippers. Our guide instructed us on determining gender by looking at pupils, size, and sound. The women are apparently more talkative... Who would have thought! I saw viejos y jovenes, mujeres y hombres, a mother alertly protecting two eggs nestled between two blue feet, some birds panting and thermoregulating with a shivering motion of their neck, some perched on acantilados (cliffs), and others in flight. They were everywhere and I was more than content. My tour was 100% in espanol, an attempt to fully immerse in the language. I've been picking up vocabulary left and right. After touring the somewhat dry and tree-less island, we embarked on the boat and parked in an area just meters from the shoreline but where the olas (waves) are more subtle. We saw huge turtles, the size of car tires swimming just beneath the surface. They swam in packs and did not shy way from the foreign sight of a boat. They swam up close and zoomed under, around, behind and in every direction they pleased. Then Explora lived up to her name and moved further from shore where we were surrounded in every direction by dozens perhaps hundreds of delfines (dolphins). In a synchronized fashion they scooped in and out of the water smoothly. On several occasions one show off dolphin would shoot straight up into the air and flop right back in stiffly holding posture. They seemed happy to entertain us and we were more than pleased to cheer in their shows. From here Explora ventured into area close to the northern coast of the Isla, where we were provided with snorkel gear. I'll admit. I almost end had a panic attack the first few minutes as adapting to breathing through my mouth, swimming with fishes of all colors of the rainbow, and swimming in the ocean... And then peace struck. I floated on the surface swimming only smoothly, following schools of fish, some small like my fingers and others much larger. They were stunning, some used abdominal muscles to sliver through the water gracefully and others used bright orange fins to paddle through the waters. There were striped fish, blue fish orange fish, plain fish, multicolored fish, and everything in between. The water was fresh, the sun bright and I was in an underwater heaven. Occasionally I felt an electric zap somewhere on my body, but we were comforted that these zings were harmless. So I swam on and on and on. Endlessly to say, I slept like a rock after this unforgettable adventure.

Day 3
Puerto Lopez, a beach town conveniently surrounded by tropical forests offers all sorts of adventure. So on day 3, we ventured into Rio Blanco land to join a local guide for monkey spotting. The hike begin in a tiny village in the surrounding foothills. There were families working in gardens, kids running in the streets, father son couplets riding motorcycles. It was precious. We were quickly sized for rain boots. Mine were a fancy bright yellow and I was even encouraged to borrow our guide's mother's Adidas pants hanging in her percha (clothesline), because my nike shorts weren't gonna cut it. I obliged and was thankful. Our hike although grade 5/5 in difficulty was quite the sight. My favorite part was the trees and the many parasitic vegetation that decorated the forest. Some parasites offered texture to the dull trees, some gave color, some provided dangling strings resembling something out of Avatar, some were just as large and prominent as the tree and creeped their way around it like a net engulfing its prey, some jut out the core and looked like sea creatures, and some bore fruit. With all the chaos and the reminiscent stories of our guide, I couldn't help think that every rope like structure was a venomous snake waiting to strike and every thing that brushed along my arm was a dog-sized spider ready to stare me down with it's many eyes. Thankfully I was repeatedly wrong. We hiked for the better part of the day before we actually heard the roars of the capuchins and other species of monkeys. They sat at the tippity top of the trees and as they creeped from on tree to the next the recently vacated branches would naturally flop back into a comfortable position. They were adorable, but high enough that detail couldn't be achieved. Their loud roars were certainly more ferocious than their lean and stout bodies. After 12 km, we returned to the small village and were greeted with a late lunch from two villager women. They tenderly cooked an elaborate meal in their casita, which was not greater than a medium sized room. The floor was dirt, the light was nonexistent, without space for cabinets the clutter was visible. This was their storage area, their kitchen, dining room, living room, and garage all in one. Something and everything hung from a nail in the shacks walls. Despite my fear of E. coli, parasites and every unfortunate microbe I learned in phase I of medical school, I ate like I'd been starved for days. Ofelia Candelaria had poured her heart and soul into this meal and had probably used the best ingredients on us, so I engulfed the chicken soup concoction; the hodge lodge of rice, lentils, boiled eggs, and beets; the fresh chicken leg (there was one less cluck in the backyard than when we arrived) and some sort of thick banana coconut juice. And I lived to tell the story.

Puerto Lopez was grand and full of outdoor adventure. I'm one shade more tan with speckled mosquito bites and unfortunately sans credit card and iPhone, but it was an adventure I'll forever cherish.

Guayaquil

The warm and hydrating climate, the drab white buildings mixed with random colonial architecture  reminds me that I am in South America. The honking horns and adventurous taxi rides with complete Spanish immersion are continuous affirmations. I've only been here one day and I'm already diving into travel mode- comfty walking shoes, makeup-less face, phone-in-hand combo replaced with camera-in-hand, and Spanish language mode switched on. I love the language challenges, or rather opportunities. In fact, Christian and  I began the day with several local newspaper articles... This was not manageable without Webster's Spanish English pocket book and google, but we were able to read about the local soccer team and of course drama at the Oscars. We began the day at Iguana Park, probably the best way to do so. The name is not misleading. There are iguanas in literally all shapes and sizes under every tree, crossing every sidewalk and just out of reach of every toddler. They slowly and awkwardly creep across the park. Some are lone rangers and others huddle in massive groups. Many of them are asleep, awkwardly folding their front arms straight along their sides giving the false appearance that there arms are broken off. They're not timid, but rather apathetic towards the eager tourists. They wander seemingly without aim and some have nubs for tails from probable encounters with bratty children or worse-traffic of the nearby road. The older ones are large and lazy with more-than-normal dryness to their scales, less than bright color to their covering and with faces like that of the Grumpy Old Men characters, double chin and all. The journey then continued along Malecon 2000, which is a recently (relatively speaking) developed area that runs along Rio Guayas for just under two miles. But it's the end of this glorious walk that is the main feature. You begin with a slight slope of the sidewalk, paved roads turn to cobblestone, drab white building transform into colorful micro-buildings and music begins to fill the air. Then you reach step #1... And continue to step 444. The climb involves passing by various cafés that could easily be mistaken for a cute house rather than business location. Many of the doorways do, however, serve as an entrance for Ecuadorean family homes. Without shame, I inconspicuously peaked into several doorframes to get a brief glimpse into the life of a local. The houses were small, cluttered, often with several children sitting in front of an archaic television set (or even playing on the window sill). The kitchens and living rooms often appeared inseparable and many middle-aged men slumped shirtlessly on the couch. At the top of the 444th step there's a small lighthouse which provides further opportunity to climb stairs, and more importantly sweat. But rest assured they had uva (grape) powerade to replenish those lost electrolytes. Today's tour included various churches, gardens, and sites. One day down,
many many more to go.

Written from Hostel Dreamkapture.