Anisia Corona

Review of a Surgeon's Reflections on Mortality

2012-01-15T00:12:00.000-08:00

In December 2008, my best friend gave me a book as I embarked on my medical mission to South America. While I was on my mission, I read roughly through a quarter of the book and positioned it on the bookshelf for the day after I finish school, right? Well, until my new friend in Australia asked me if I had ever read the book. Since my copy was waiting for me in my storage back home in America for when I finished school, I took the offer to borrow her copy. Now, in January of 2012 as I prepare for my medical exam admissions test in Australia, I finally finish the book.

The book is "Final Exam: A Surgeon's Reflections on Mortality" written by Dr. Pauline W. Chen, a liver transplant surgeon. Dr. Chen describes how she began writing about her experiences with death, particularly about the one hundred liver transplant patients she pronounced brain-dead during her transplant fellowship, in an attempt to deal with the truth of what she has become. Through writing, Dr. Chen realized that her own fears about death and her medical training were what had incapacitated her to give her patients what they really wanted. She learned that while she provided comfort to her dying patients and their families, she was learning propitious and necessary skills.

I feel a little like Dr. Chen in the way I started this blog. Writing about my experiences has not only helped me remember the details and processes that I would soon forget as I crowded chemistry and physics in my brain, but it has also gave me an idea of how I think and process all the death I experience. I have always enjoyed writing and actually dreamed of being a writer as a child. When the reality of having a career that would provide me an income was instilled on me by society, I dreamed of writing for a health and fitness magazine. Now possibly, I dream of being able to publish in The New York Times or The New England Journal of Medicine.

Dr. Chen describes one of the most important lessons she learned from her attending surgeon during the death of one of her patients with colon cancer that had spread to his heart and lungs. Prior to the patient being transferred to the ICU, the patient's wife expressed her concerns to Dr. Chen about her husband dying at home. Following the transfer, Dr. Chen was not able to fulfill the patient's need but watched her attending surgeon in an act that would lead her future character. The attending surgeon took the wife's hand and quietly explained what was happening when life leaves the human body. He then gently lead her to the room where her husband was dying and closed the curtain around the three of them. The surgeon stood at the woman's side, whispering in her ear about the process of death. He pointed to the monitors explaining the final contractions of the heart. He pointed to the patient's chest explaining the final and irregular breaths. Finally, he explained the most powerful reality of all- that the patient was aware and comforted in the presence of his wife. In response to the way the attending surgeon had conducted the death of his patient, the patient's wife wrote a note to the hospital. The note said: "although my husband did not die at home, as she had always hoped, he had died a dignified and peaceful death. And that was all we really wanted." Dr. Chen learned not to slip away from her dying patients. She learned how to perfect explaining the process of dying, touching family members, embracing those that looked particularly lost and telling them the comfort of their presence.

Dr. Chen goes into detail about the M & M (Morbidity and Mortality) conferences founded by Dr. Ernest Codman in the 1900's. In the early 1970's, Charles Bosk, a sociology graduate interested in how surgeons dealt with error and their drive for perfection, wrote about the sociology of bioethics. He has worked on manuscripts such as, "Thirteen Ways of Looking at a Medical Error". He learned the fact that surgeons had to make tough decisions and how strongly they were held accountable for those decisions. In 1983, accredited surgical residency programs were required to conduct weekly M & M conferences. Bosk explains that the M & M conferences were special rituals for witnessing errors, resolving confusion created by the errors, and incorporating the error into the surgeon's history. The surgeon is put in the spotlight of his colleagues and asked simply how they account for the death of their patient. Just occasionally are the deaths caused by a disease's natural course, instead more often to the error of a surgeon's mistake and categorize it as an error of technique, judgement, diagnosis, or management. So in the end, the primary reason for any death is dependent on the attending surgeon's actions. Dr. Chen believes that by defining death as a result of errors, such as the ritual of M & M conference, we erase the face of our patients and insert our own fiercely optimistic version of immortality and denies our essential humanness. In refusing to accept our own imperfections, we deny ourselves grief and in turn prevent us from giving patients the best care.

The book also reflects the breakdown of the medical curriculum. Dr. Chen clarifies the potential risks involved with the current curriculum. I was recently lead to an article in The New England Journal of Medicine written in July 2008 by Jules L. Dienstag, the dean for medical education at Harvard Medical School. He speaks on the relevance and rigor of the premedical education in preparation for medical school. He explains that with the newly focused curriculum, pre-medical science pregenomics.

For example, students could do a two-year chemistry course in undergrad that teaches the biological-relevant general chemistry, organic chemistry and biochemistry. In this sequence, instead of a second semester of organic chemistry, students would take a fundamental biochemistry that includes a preparatory organic chemistry section. College math would focus on biological algebraic and trigonometric quantitative skills with adequate grounding in probability and statistics used in scientific and medical literature. The more important subjects- ethics, altruism, compassion, listening skills and skills relevant to health policy, and economic- would be taught in new medical school curriculum because the base work for biological sciences would have already been completed in a student's undergrad. This curriculum mirrors more the way biologists and physicians navigate through and solve the problems of today in health care.

The MCAT is also suggested to conform with these new scholar requirements. Such as the importance of introducing synergy and efficiency through cross-disciplinary and biologically relevant teaching. The curriculum would encourage inquisitive students and reward those with the knowledge of more specific, biological relevant sciences. Or maybe the MCAT could mirror the topics included in the Australian version of the admissions test called the UMAT: logical reasoning and problem solving, understanding people, and non-verbal reasoning. Here is an example of a question in the understanding people section:

Bob's wife, Mary, has been in the hospital recovering from a heart attack. The doctor informs Bob that she is now well enough to return home, although she will needs to 'take things easy for awhile'.

Bob: "I'm glad she can come home now Doctor, but I'm not sure I can look after Mary by myself. We live on our own, you know."
Doctor: "Bob, it's natural to feel a little anxious, but the best thing for Mary will be to be back in her own environment."

1. In his response, the doctor has:
A. not realized that Bob is concerned
B. not really dealt with Bob's concerns
C. responded to Bob's concerns effectively
D. made Bob feel bad about being concerned

2. Following the doctor's reply, Bob is likely to feel:
A. relieved
B. empowered
C. embarrassed
D. apprehensive

(Answers: 1. B 2. D) These types of questions should be included in the MCAT to properly suggest that it requires human understanding and communication to be a good doctor, and as Dr. Chen has suggested in her book, that in order to be a good doctor you must stand in one's shoes.

Dr. Chen, like many, believed that all the work hours and curriculum would turn her into a well-trained surgeon, but in the heat of the everyday moment that lofty goal rarely entered her thoughts. Instead it was was anxiety for all the tasks left to her responsibility in a given day. Her un-questioning acceptance of the training and the work hours were driven by the fear of killing someone. The fear kept her up at night, steered all her attention to her patients and to re-check her paperwork for perfection. Most importantly, it changed the way she talked to her patients and lead her to send difficult, time-consuming problems to someone else (aka turfing in medical jargon).

Over the past few years certain training programs, specifically surgical training programs, have enforced work hour limitations in an effort to decrease sleep deprivation, improve quality of life, and presumably enhance patient care. Although the residents today spend less time than the residents years ago in the hospital, there are some displeasing results. The increased free time has left residents with less time to properly bond with patients. The training program pushes for more time in the OR than with the patient. This result is a self-inflicted guilt among surgeons. The tension from the clinical responsibilities and the lack of time to spend doing it "good enough" builds up. They hold values on themselves but can not live up to them. Over time, the less urgent task: patient-centered quality time seems to take the hardest hit.

A study showed that intense workshops could help physicians improve their skills in speaking with patients. The problem with these self-help orientated workshops is that physicians refuse to participate in them, even when offered a free admission into a research study, due to a lack of time. Hospitals should reward physicians who spend time improving their patient-care relationship skills.

Research of 1,000 physicians in England showed over time that certain personality traits were protective against professional burnout. The physicians who were more extroverted and open to new experiences tended to fare better and to complain of less stress than their counterparts. But just as biology has proven with nature vs. nurture, most of these traits can be developed. A physician can acquire these ideal traits to prevent burnout.

I title my blog, Diligently Creating The Perfect Thing. As I strive for perfection, my character is reflected in that. It can be a two sided sword at times. As much as I am diligent and determined, I can take non-judgemental comments as- you did not do this perfectly. I am faced with an internal struggle of guilt and shame that feeds my fire for proving the world wrong. I related to the struggles of perfection, human connection, and facing death that Dr. Chen discussed in this book. I feel I've learned a little more on what it takes to become that perfect surgeon.

Here is a link to the author's blog where she continues to share more insightful information.

Ulnar Nerve Transmission Surgery

2011-10-12T22:24:00.000-07:00

My mom asked me to be in the operating room for her surgery... I made it to La Paz, Bolivia in 27 hours to be there. Dr. Diego Soruco and Dr. Juan Carlos Cruz allowed me the opportunity to film the surgery...

Laparoscopic Cholecystectomy Surgery

2011-10-09T17:06:00.000-07:00

Back at the Hospital Juan XXIII in La Paz, Bolivia I was given the opportunity to assist in a Laparoscopic Cholecystectomy surgery on October 7, 2011. It was to be my first laparoscopic surgery on a live person. I had experience assisting with laparoscopy surgeries using cadavers at the Surgical Training Facility in 2008.

Cholecystectomies (Gallbladder Removal Surgery) are very common in Bolivia, as noted in a prior blog. Gallbaldders are removed because of the inadmissable pain caused by the movement of the bilary colic (gall stones) inside the gallbladder itself. The gallbladder is a digestive organ used to store the bile that digests fatty foods in the intestines. The gall stones actually initiate their growth in the liver. Under normal conditions, the liver is able to detoxify itself and dispose of any cholesterol via stool. In the case for most Bolivians, that consume a large quantity of cholesterol containing meats, excess cholesterol crystallizes in the liver and combines with the gall stones. The overconsumption of large cholesterol molecules in the liver lead to the evolution of the gall stones, that eventually make their way from the liver into the gallbaldder through the hepatic duct. A further problem occurs if a gall stone blocks the opening of the gallbladder where the bile is released. This causes a build up of destructive chemicals inside the gallballder. In combination with oppresive movement of the gall stones inside, the only treatment is to remove the gallbladder.

There are two methods of this procedure. The first method is the traditional open cholecystectomy where an incision is made just below the ribs on the right side of the chest. This method provides a better view of the anatomy for the surgeon but the recovery and hospital stay is the longest. The second method is the laparoscopic procedure invented in 1989, which allows the surgery to be performed through four small incisions in the chest and requires less recovery time.

The surgery started with an incision at the navel on the patient under general anethesia. The patient's chest had been inflated with carbon dioxide to allow proper vision in the abdominal cavity. The surgeon demonstrated this by playing drums on the patient's stomach. The laparoscope was inserted into the incision made at the navel. My responsibility in the surgery was to manuever the laparoscope inside the abdominal cabvity to allow the surgeon proper view of the gallbladder. Another three incisions were made on the right side of the cavity, one more lateral then the other two. The surgeon stood on the left side of the patient with two instruments in hand and I stood at his left side manuevering the laparoscope. The other instrument was clipped to the patient. Using the view provided by the laparoscope's camera, two grasping instruments were inserted into the two incisions. With the two instruments, the surgeon began to identify and initiate cutting away at the connective tissue holding the gallbadder in its place.

The gallbladder is surrounded by the liver and the duodenum of the small intestine. There are also three important ducts: one called the common hepatic duct with left and right branches stemming from the liver into the gallbladder, one that stems from the gallbaldder to the duodenum and one that forms a link between the common hapatic and cystic duct called the common bile duct. The cystic duct is the most important duct to distinguish from the others to be able to release the gallbaldder from the other organs. It was very important to prevent any other ducts being mistakingly cut, clipped or nicked.

Within minutes of initiation of the removal of the gallbladder, I began to feel excessively hot and the heat from my breath began to fog up my glasses. Then I began to feel an extreme urgency for oxygen. Having already scrubbed in and being sterilized, I could not move my mask to get more air. I felt suffocated and tried to concentrate on my breathing. As the heat flashes continued, I tried to convince myself that it would all go away if I just stayed calm. I stared at the camera's screen with the intention of focusing my energy on my work, until I noticed that I was having successional blackouts. Then the surgeon nudged me and said,"stop shaking". I looked down at my hand and noticed in humiliation that I was uncontrollably shaking. I grabbed my wrist with my free hand with intent to stabilize it.

I felt extraordinarily drained and began to drift off. I envisioned myself passing out, as it was the easiest escape, but I was determined to dominate the situation. The surgeon gave his final request for me to follow him with the camera. I turned to the surgeon and said,"I appologize, but I've lost my vision". The surgeon asked if I was sick and for one of the residents to enter the operating room to take my place upon my confirmation. Minutes later I was sitting on a chair in the corner of the operating room. I could feel the sweat soaking into my sterilized gown, dripping down my face and onto the hands of the anesthesiologist as she took my mask off. As I sat in that chair with an oxygen mask over my mouth and nose, I tried to stay as consious as possible. I knew my brain was not in commission with the idea of me standing right back up and continuing to deliver the best camera view for the surgeon so I stared at the camera's screen, trying to stay with the surgery and trying to concentrate on my breathing.

The surgeon continued to remove the connective tissue cohering the gallbladder to the liver and duodenuom. Once the gallbladder was freed from the surrounding organs and the cystic duct, the surgeon began to clean up what was left in the abdominal cavity. Gauze wrapped in a cylinder shape was pushed throught the instrument's tube to assist in the collection of blood in the abdominal cavity. The gauze was soaked in blood, left over from the removal of the gallbladder, and pulled back up through the instrument. A suction was also used to collect the blood. A Bovie, powered by an electrosurgical generator, was used to burn the surrounding organs and tissue in an attempt to cause coagulation. Finally, the gallbladder was removed through the instrument and placed in a dish. An incision was made at the top to allow the gallbladder to be drained. Liquid and small black gall stones drained out as the surgeon left the operating room with the dish to demonstrate to the family the need for the surgery.

The carbon dioxide was removed from the abdominal cavity of the patient and the incisions were stitched up. An abdominal drain, for the removal of abdominal fluid and pus, was prepared on the right side of the patient with an incision and a tube. The tube was left in the abdomin and came out throught the incision. The surgery lasted about an hour and the expected recovery time is shorter then with the open cholecystectomy method. Upon termination of the surgery, my near syncope experience was assumed to be derived from a bit of anticipation in assisting the surgery and due to the altitude change, since I had only been at 12,000 feet for only three days.

Cholecystectomy is not always the best option for the relief of gall stone pain. It depends where the gall stones have accumilated. There is a chance that not only are the gall stones in the gallbladder, but that they are still in the liver or ducts. A study (1) performed in 1987 showed that 15% of patients who under went a cholecystectomy still had persistant pain. Upper abdominal bloating and psychiatric medications were predictive of their symptoms. Another study (2) performed in 1996 showed that dyspeptic (upset stomach and indigestion) symptoms inproved in 40% of patients and symptoms increased or developed in 17% of patients postcholecystectomy. These increases in dyspeptic symptoms are titled postcholecystectomy syndrome (PCS) and it is suggestive that the duodenogastric reflux may play a role in these symptoms. Second opinions are always recommended prior to any surgical procedure. To each his own.

(1) Ros E, Zambon D. Postcholecystectomy symptoms. A prospective study of gall stone patients before and two years after surgery. Gut 1987; 28:1500-4

(2) Luman W, Adams W H, Nixon S N, Mcintyre I M, Hamer-Hodges D, Wilson G,

Palmer K R. Incidence of persistent symptoms after laparoscopic cholecystectomy: a prospective study. Gut 1996; 39: 863-866

2010 Update

2010-11-10T13:17:00.000-08:00

Over the past months, when I wasn't keeping up on my blogging, I was employed by a company as a clinical research coordinator. I worked for a private contracting company employed by pharmaceutical companies performing clinical trials with physicians to get drugs approved by the FDA. I enjoy research because it has given me the opportunity to learn about the millions of diagnosis, working with patients and medicine, which seems to be one of the primary things physicians use to help "cure" a patient. One of my favorite studies was a testosterone gel for women who have lost their libido. The testosterone showed to increase sexual events from 2 events to 6 events per week. Women infrequently showed any side effects, such as hair growth or a deepening of the voice. The drug should be approved by the FDA within the next year and I would recommend it for post-menopausal women with a complete hysterectomy or pre-menopausal women who have lost their libido.

Although I enjoyed my work, I was very unhappy working for a company who was money driven and whos moral was completely different from mine. I stayed in the company for ten months too long. I stayed because of all the things I was learning, even after being threatened, bullied, manipulated and insulted by my supervisors. I saw people leaving and thought - I will put up with it for now. What a huge mistake! When I got out, I realized how un-healthy an environment like that was and that I will never, ever put myself there again. I was working 40+ hours and didn't make time for anything that made me 'me'. I hadn't even trained for one race and stopped hanging out with friends. I put my life into my work trying to prove I was better then what the company told me I was. Thankfully, I had a very supportive boyfriend who helped me get through it.

I began job searching in September in both the Los Angeles and Phoenix area. Although I was offered positions in research in Santa Monica, Beverly Hills and Covina, I accepted a job in Scottsdale. I was thrilled about the idea of moving back to California (and Santa Monica where Greg is now living) but the California jobs weren't paying as much and the cost of living would have been twice what it is in Arizona. I worked for the D.O. in Scottsdale for a little over a month and realized it wasn't the best learning experience for me. I was only seeing 3-4 patients a week and I needed to be around more people.

I have plenty to do now with a Physics class, volunteering in the Emergency Room, MCAT studying (I'm taking the MCATS in March!) and possibly starting an MBA program until I get into medical school. Most importantly, I want a place where I work hard, am appreciated for it and can smile everyday without intimidating micro-management.

I have plans to become a physician and start my own business. I've learned how I do not want to run a company. You must have codes that you follow to the T that demonstrate to the world who you are... I want to be a leader in the community, be able to solve health issues that effect everyday lives and be a good example for my children. Quality over quantity. These things are what motivate me.

I am in my last semester of Physics at Scottsdale Community College. Last semester, I ignored the world and deservingly stole an A in the class. I unanimously appreciate my Physics instructor, who believes that hard working students should receive an A. He sets up the class for us to succeed and effectively sets the tests up for us to show that we do know the material. He has also been doing a really good job of preparing me for the MCAT.

I am 30 years old now. This is just the start of a beautiful life... stay tuned.

I did leave my ♥ in San Francisco

2010-02-06T22:30:00.000-08:00

I moved to Arizona in July from San Francisco. Those close to me told me not to leave San Francisco. I heard them out (well kinda... barely... ok not really). So I can be stubborn sometimes. I didn't realize how much they may have been right, till now. It has been an immeasurable change for me. I came back to the place where I grew up, but to the place that I am no longer "from". I had lived in San Francisco for more than eight years, long enough to consider it "home". In the eight years that I lived in San Francisco, I grew to eulogize the culture; appreciate the unconventional people, the habitual crave to travel and the energy of being in one of the most beautiful cities in the world. It was in San Francisco where I learned to be proud and take advantage of my ethnicity, where I initiated the magnitude of my comfort zone and into the profound world of triathlon, where I became friends with the most intelligent people, and where I explored my soul in the endless communities of trees, hills, music and restaurants. San Francisco completely transformed me, and for that I am indebted.

Since moving to Tempe, I have been happily working full-time in medical research with doctors for several different pharmaceutical companies. I adore and utterly appreciate my work. We are currently enrolling subjects for several different research studies that I am proud to be apart of. I am also enrolled in classes at Scottsdale Community College, with the goal of finishing my prerequisites for medical school. I have also moved from an apartment with Greg near Papago Park, to an apartment on Tempe Town Lake. Greg is now living and training in Boulder, Colorado where he is perfectly enjoying the energy he gets by being encompassed by some of the best endurance athletes in the world and I enjoy receiving his gifts in the mail.

I am glad to be close to my dad, who lives just a few miles from my work. He had a heart attack last week and I was so grateful to have been able to get the chance to immediately go visit him in the recovery room after his stent procedure. I felt like I've missed out on a lot of his life, since I lived in California. I'm lucky to get the chance to see him often now that I'm in Arizona.

On the mark of my sixth month of being back in Arizona, I am sharing my life with pictures; a comparison of my life in the city to my life in Arizona during the past few months...

SAN FRANCISCO:

Hanging out with my favorite brother and sister, Anja and Mark Strehlow

University of San Francisco Medical Center

Sam's Cafe- Tiburon, California

California 70.3 Triathlon- San Diego, California

Hiking in San Luis Obispo, California

Weekly run along Crissy Fields

Swimming near Angel Island

Yearly trip to the Wildflower Triathlon- Lake San Antonio, California

Silicon Valley Triathlon- San Jose, California (Greg leading the pack out of the water)

Looking for parking, picking up a ticket off my windshield, or moving the car every two hours in front of my loft!

San Francisco State University Track

Weekend getaway in Napa

Swimming in Aquatic Park

Riding to the Mendocino Coast

Sailing under the Golden Gate Bridge

Cheering at Escape from Alcatraz Triathlon

ARIZONA:

Amica Sprint Triathlon at Pleasant Lake, Arizona

Pleasant Lake, Arizona (Greg leading the pack out of the swim)

Hiking Squaw Peak Mountain- Phoenix, Arizona

Brophy Masters Swimming- Phoenix, Arizona

Brophy Track- Phoenix, Arizona

Hiking Camelback Mountain- Phoenix, Arizona

BackStreet Wine Bar with family- Phoenix, Arizona

Seeing high school & middle school friends again- Scottsdale, Arizona

Running the endless trail at Pleasant Lake, Arizona

Arizona Ironman- Tempe Town Lake, Tempe Arizona

Trip to see the Remaly family- Boulder, Colorado

Spending time with friends who are like family

Running right outside my apartment along Tempe Town Lake

Passing Mill Ave Bridge while running at night on Tempe Town Lake

13.1 Miles In Honor of Ryan Kloos

2010-01-19T19:54:00.000-08:00

"Wondering around our America has changed me more than I thought. I am not me anymore, at least not the same me I was inside." - Che Guevara, The Motorcycle Diaries

The Haiti Quake has touched me on a personal level. My friend of two months and co-worker, Ryan Kloos, went to visit his sister volunteering at an orphanage in Haiti and got caught under the falling of the five-story building and died. Ryan's sister, Erin Kloos, had been a volunteer at Friends of the Orphans for several months. Ryan had gone to visit his sister for a few days because he knew how happy she was there, and he wanted to explore Haiti for himself.

Ryan Kloos was an intelligent, witty, humorous, athletic, and friendly guy. Ryan and I shared a passion for the sport of triathlon, among many other things. He was a collegiate swimmer for UCSD and told with me how he would come out ahead of the pack during the swim and bike of a triathlon, and how he was working on his running. Working on his weakest sport meant pushing his comfort levels. The week Ryan left for Haiti, he told me how excited he was to have had ran 11 miles in preparation for the Rock'n'Roll Half Marathon he was to run, upon his return from Haiti. We touched on the fact that I would run it as well, but I admitted to him that I wasn't ready for it and decided not to run it with him.

Upon hearing about Ryan's death, I decided to run the Rock'n'Roll Half Marathon in honor of him. I collected Ryan's race number and shirt, and signed up for the race myself. Channel 12 News interviewed me outside the Rock'n'Roll Expo:

On the morning of the race, I prepared myself for racing like I'd never raced before: untrained, no watch, and running in a demeanor that was so selfless. When the race started, I was so relaxed and I knew I wasn't alone. I had pinned Ryan's picture to my race belt. At mile 10, two women caught up behind me and asked me who my friend was. They said they had seen him in the news. I introduced them to Ryan and they asked me if they could pace with 'us'. One of the women yelled out our pace at each mile leading to the finish line. As our pace emerged into a faster one, she yelled out, "Thanks for pushing us Ryan"!

There are few people in this world who go out of their way to get to know people, know people's identity. There are few people who influence everybody, who impact everybody. That was Ryan. Ryan had just been accepted into medical school and was planning on attending in the Fall. He would have made an impressive doctor. He also volunteered at a homeless shelter on Fridays, his only day off. With a double major in biochemistry and cell biology, Ryan not only had the intelligence but the social skills to communicate his knowledge so well. I admired Ryan's interactions with his patients, as well as his knowledge of all things science.

If you are interested in donating to the Haiti Quake, please donate on behalf of Ryan and Erin Kloos to Friends of the Orphans.

"Let the world change you, and you can change the world."

- Che Guevara, The Motorcycle Diaries

Bypass Surgery

2009-06-24T16:10:00.000-07:00

I got the opportunity to observe my best friend Anja Strehlow, a physicians assistant in cardiothoracic at the University of San Francisco Medical Center, remove the saphenous vein from the left leg of a patient having bypass surgery. The screen represents the screen that Anja had sight of while using endoscopy to cut all the attaching blood vessels from the surrounding tissues to remove the vein. The doctor requested the length of the patient's whole thigh and then later requested about 2 inches into the leg.

The picture to the right, shows Anja taking out the vein

Ascending Aorta Replacement Surgery

2009-06-23T18:40:00.000-07:00

An ascending aorta replacement was performed by Dr. Merrick on a 53 year old female with an enlarged aortic valve. A sternotomy was performed and the patient was put on a cardiopulmonary bypass, as seen in the mitral valve replacement. The sternotomy, performed to get access to the heart, can be dangerous- I was told the aorta was accidently cut through during this procedure the other day. The medical team worked quickly together to suture the hole in the aorta, as well as prepare the bypass through the femoral artery in the mid-thigh (where a great deal of blood is pumped through to get oxygenated blood to the lower body), instead of using the ruptured aorta.

The incision made into the heart was at the location of the ascending aorta, above the sinotubular junction and below the aortic arch. Blood enters the annulus through the aortic valve coming from the left ventricle. The aorta carries oxygenated blood from the heart to the rest of the body for gas exchange within the cells.

Stenosis is a narrowing in the aorta (as shown above). Instead this woman's case was different, the aortic valve was larger than normal and in need of a replacement. The aorta was cut through (as shown in figure B). The destroyed tissue was removed with scissors, leaving two flaps on each side called pericardial patches (shown in figure D as dotted lines near the bottom of the aorta). These flaps were used to eventually suture the prothetic valve tighter into the aortic orifice. Sutures were laced on the exterior edges of the aortic orifice to pull in the new aortic prosthesis (as shown in figure C and D). A hole is made by burning each side of the prothesis tube to make an entrance for the right and left coronary arteries to enter.

Every time a prosthesis is used, it must be opened as a new package. Usually the medical device reps are in the OR ready to open the prosthesis for use in surgery. Today the nurse miss-understood the surgeon and opened a new prosthesis that wasn't the right size. It was a $5,000 mistake.

After the heart-lung machine was disconnected and the heart began to beat again on its own, there was an obvious leak of blood from a hole in the aorta from behind. There was no easy way to push the heart out of the cavity and suture the hole, but eventually it was found and fixed. We were lucky not to have had to go back onto bypass because it would have taken at least two more hours.

I was really lucky to have had the chance to observe my first surgery with my very smart and beautiful best friend, Anja Strehlow. She works as a Physicians Assistant in cardiothoracic and previous PA in my former orthopaedic surgery department. She has always been an inspiration to me in the medical field and has supported me in reaching my goals in all aspects of my life. Tomorrow I'm even more excited to be there to watch her do her thing as she removes the coronary artery from the lower leg for a coronary bypass surgery.

Mitral Valve Replacement Surgery

2009-06-17T16:30:00.000-07:00

During my first day in UCSF's Cardiothoracic Surgery department, I got to observe a Mitral Valve replacement surgery (aka open heart surgery with cardiopulmonary bypass) performed by Dr. Merrick and a female second year fellow. After a little over five hours of standing on my feet, I am a little more experienced on how our cardiopulmonary system works. Made up of the heart and lungs, the cardiopulmonary system receives de-oxygenated blood to the heart through two tubes called the superior and inferior vena cava. Then the de-oxygenated blood flows through the tricuspid valve to a lower chamber called the right ventricle, and then off to the lungs to get oxygenated. Once the oxygenated blood returns from the lungs into the left atrium, it is pushed through a valve-type tissue called the "mitral valve" into the left ventricle. From the left ventricle, the oxygenated blood is pushed through a tube called the aorta to the rest of the body.

In the case of the need to repair or replace the mitral valve, the oygenated blood from the left ventricle is pushed back through the mitral valve into the left atrium- a process called regurgitation.

This shows the normal blood flow within the heart. The mitral valve properly allows the movement of blood into the lower chamber of the left ventricle.

The mitral valve insufficiency means the valve is not closing, allowing blood flow back into the atrium. The atrium grows and this can lead to heart failure if left untreated. Mild regurgitation remains asymptomatic while moderate to severe cases cause abnormal rhythm problems and shortness of breath.

Usually acute regurgitations are caused by a rupture in the chordae tendinae, the long cords extending into the left ventricle from the mitral valve, during a heart attack or other trauma. When the chordae tendinae aren't working properly, the blood volume increases in the left ventricle and causes an increase in pressure in the chamber above. This can cause shortness of breath, fluid accumulation in the lungs, or the body's cells die from starvation of oxygen and nutrients due to the lack of oxygenated blood flow.

After putting the patient completely out via anesthesia, a transesophageal electrocardiogram, aka ultrasound, can evaluate the blood flow through the mitral valve. A probe with a transducer is inserted into the esophogus where the waves echo the heart structures. It was easy to see that the valve was allowing blood flow back into the left atrium when the heat setting was established on the screen. Every time the left ventricle pumped, instead of sending the oxygenated blood solely to the aorta, it flowed forcefully back up into the chamber above. Due to the amount of blood and the force of it, the surgeon decided to perform a mitral valve replacement instead of a repair. Although repairs have shown to be more successful because of the ability to have human tissue instead of a prosthetic one inside the heart, the mitral valve wasn't repairable and a replacement was the only option for this patient.

The most fascinating thing about the mitral valve procedure is the ability to do surgery on a non-working heart by use of a cardiopulmonary bypass. The heart-lung machine replicates the job of the heart (to oxygenate the blood and get it to the rest of the body) so that the heart can stop pumping during the procedure. The heart, a working muscle, is located in a small chamber within the thoracic cavity. Above is a picture of the heart as it lies inside the thoracic cavity- the sternum bone and its attached rib cage with inner lying intercoastal muscles. Below the heart is an underlying muscle tissue called the diaphram that seperates the thoracic cavity from the lower body. The incision for the procedure is made along the dotted lines, shown in the picture above. A median sternotomy incision is performed (the sternum is sawed down the middle with a sternum saw), allowing an ideal view of the beating heart once the retractors are in place.

All the tubes shown in the photo to the left are the tubes that take the place of the beating heart. Cardiopulmonary bypass involves making a small incision in both the superior and inferior vena cava and inserting a special tube connected to the heart-lung machine. Another incision is made in the aorta and connected to the opposite end of the heart-lung machine. The inserted tubes insure that blood leaves the body before reaching the heart and returns back to the body, allowing the surgeon a still and bloodless area to work with. The constant pumping machine, guided by the perfusionist, works as the heart would by taking the de-oxygenated blood to be exchanged for oxygenated blood and then directed to the rest of the body to exchange among the other cells. The de-oxygenated blood is directed to the machine's resovoir, then to the oxygenator, and then through the pump to be pushed back into the body. I found it to be so amazing how the machine (refer to photo below) is capable of doing the heart's job to allow the heart to be worked on for the procedure, especially the ability to exchange carbon dioxide for oxygen. Once the bypass was set up, 32 minutes after the incision, the heart lost its size inside the cavity and shrunk as it came to a complete stop. The screen that once demonstrated the heart's pressure, EKG, and voltage became clear. Then, like magic, the heart's information appeared on the heart-lung machine's screen. The heart sat in its place silently and the patient continued to live- wow! One of the surgeons told me that the one thing that has stuck with him through medical school were the three things that are needed to keep a patient alive: 1) oxygenated blood 2) blood flow throughout the body 3) continued urination which allows filtration of the blood. With help of the heart-lung machine, these three important factors are allowing the patient to stay alive.

The most important part of the procedure is keeping the heart at a mild hypothermic level of 34 degrees Celsius. This cold temperature decreases metabolism and helps protect major organ systems from a lack of blood flow because for every 1 degree Celsius drop of body temperature, the metabolic demands of the body are decreased by 7%. Ice was constantly placed inside the thoracic cavity and when levels rose, the procedure was put on hold until the temperature was confirmed to be at a hypothermic level. The blood that ran through the heart-lung machine was also kept at a low temperature for its return to the body. A third tube is also connected to the heart, but not to the heart-lung machine. This tube flushes the heart with cardioplegia, a potassium chloride solution to stop the heart without damaging it. An increased amount of potassium levels in the blood is a condition called hyperkalemia and is what causes heart failure, which is why it is a third of the ingredients for lethal injections.

Once the heart is in view, an incision is made in the right atrium, bypassing the septum to the left atrium. The surgeon's view is directed downwards, looking through the mitral valve into the left ventricle. The mitral valve is examined and determined eligible for a replacement.

A replacement is sized and the replacement procedure begins after the damaged mitral valve and tissue are removed. Several sutures, surrounding the circular shape of the mitral valve are performed (refer to photo on right). The prosthetic mitral valve is sutured into place and procedures for closing the heart are initiated. Before the heart is closed, the blood is warmed and the heart is slowly returned to pumping its own blood. The blood lost during surgery is rinsed and slowly returned to the heart as it regresses to its normal behavior. The sternum is finally sutured closed using extra think bone needles and wire.

Watching the human heart beat really adds to the fascination that I have for the human body, and more importantly it increased my appreciation.

Below is an animated video of the procedure...

Closer To Reaching My Goals

2009-06-07T09:14:00.000-07:00

"For everyone who asks receives; those who seek find; and to those who knock, the door will be opened." -Matthew 7:8

Fall 2009 semester is over and I am now focusing my time on a successful transition back to my home town of Arizona after 8 years of being away for school. During my last few weeks in San Francisco, I will be observing in the UCSF Medical Center's cardiothoracic department and searching for a position as a full time medical assistant or pharmaceutical sales rep in Arizona. Both of which shall give me motivation to write about.

As part of my prerequisites for medical school and the MCATS, I took Calculus and Organic Chemistry this semester. Calculus went increasingly well, especially since I had one-on-one assistance from my boyfriend Greg and my teacher, Addie. Greg tutors kids in math so he had the patience and experience to help me be successful. Most of the time, Greg helped me with the basic algebra needed to solve the new calculus concepts. Greg was always available for me, even spending time to help me before or after spending 8 hours tutoring kids and his training. My teacher also took so much time to be available for me during her office hours.

The organization of my class was a new concept that was being tested and studied. It consisted of three days/week hour-long group study time where each small group would discuss and solve several problems that applied to how we would use calculus in the real world. Some of those problems were then due the next week with a full written out explanation of how it was solved. Then we had two lectures online/week which lasted from an hour to hour and a half, weekly online homework with a tutorial to help solve the questions and three big exams. The online homework usually took from 2-5 hours to complete, usually the latter. We were given a fake exam that replicated the real exam and allowed a cheat sheet during the exam. Overall, I think that the new organization of the class was successful and allowed me to get an understanding of Calculus from all the different ways there are possible for learning. I got A's on the last two exams and an overall B in the class.

For the first few weeks of school, I was registered in Organic Chemistry II- the second and last semester of the year of Organic Chemistry needed for medical school. I was enrolled in the post-bach program's class since it was the only one honored during the Fall semester. The teacher told me that if I wanted to stay in this exclusive class, I would have to do really well on the first exam to prove myself. I had to prove myself because the pre-med post-bach students were paying $50,000/year to be in prerequisite classes with the best teachers and most of them were passing them with A's. I wasn't enrolled in the pre-med post-bach program because I wanted to save money. I studied hard but did not do well on the first exam. The teacher advised me to re-take Organic Chemistry I- the first semester of Organic Chemistry.

I enrolled in the lecture for Organic Chemistry I that same day, which was just in time for the deadline. My lecturer was a teacher I had a previous semester for lab. He was from China and did not pronounce the english language well, in fact I did not understand a word he said. His lecture consisted of power point slides with pages directly from the book so I printed them out, read each one and then took notes while reading each chapter in the book, and took well advantage of my dry erase board by re-writing all the reactions over and over again. I attended only one of his lectures, but read page for page of every chapter in the book. I got an A on the final and an overall A in the class.

I think this semester was a success because I didn't have a job or a race to train for and really spent all my energy into completing my Calculus homework and reading every chapter for Organic Chemistry. Plus, there was no way I could fail with nothing to complain about... I have an amazing boyfriend to look up to for working 10 times harder than I do and a perfect place in the city with a parking spot!

I made time to swim three times a week for an hour with Greg at the Burlingame Aquatic Center, lift two times a week at the SFSU gym, and bike or run at least twice a week. My training plan was just maintenance throughout the semester. Ever since classes have ended, I have been committed to getting back into training for racing my next triathlon. Teana and I will be racing Nathan Tempe Triathlon September 27th. I have a 16 week plan that focuses on improving my swim and bike portions of the race, leading up to nine hours of biking through out my peak week and a consistent five days/week of swimming. I'm really excited to be able to train with Teana in Arizona and we're living only a few blocks away! I hope to see a lot of improvement in the both of us for this next race and in everything else I have planned, as I reach closer and closer to my goals.

Afra and I in Las Vegas in March during my spring break road trip to Arizona.

Teana and I in Arizona.

My sisters and I on the top of Camelback Mountain in Arizona.

Greg and I at the Wildflower Triathlon in May.

Greg and I swimming in Lake Mendocino the day after my last final.

Greg and I biking Orr Springs Rd. during a trip to the Mendocino Coast.

The Balancing Act

2009-04-06T14:05:00.000-07:00

On the path of becoming a physician, I have faced the famous challenge of the balancing act. This Spring 2009 semester, I have decided to follow the advice of my pre-med academic advisor, Dr. Rothman and slooooooooooow down. Slowing down would allow me the ability to focus and be more tentative to the task at hand. Slowing down would mean putting all my effort into my pre-requisites for medical school and would also mean stop competing in triathlons. I respect the advice from my advisor, but triathlons are such a huge part of who I am and what makes me shine. Succeeding at this balancing act was my goal for the semester and so far into the semester, I am feeling very confident about my results.

In February my twin sister, Teana joined my boyfriend, Greg and I in The Desert Classic Duathlon in Phoenix, Arizona. I participated in it because it was a short race at the beginning of the semester that I could be ready for by training during the winter academic break. After returning from Bolivia, where I avoided training at such high altitudes, I had a month to build enough endurance to at least beat my twin sister who was competing for the first time with me. It was such a joy to watch my sister finish her first run/bike race and to participate in a race with Greg for the first time as well. Greg also got a chance to check out the Scottsdale/Phoenix area's training environment so he can have a successful season in triathlon.

Teana racing with my 2009 Specialized Allez road bike in her first race ever.

I am following the advise of my advisor and have postponed my goals of competing in the Arizona Ironman November 2010 and will not be training for any triathlons this Spring 2009 semester. Fortunately, my life is still filled with the sport because of Greg. I have been able to live in the sport through his training, watching him reach his fitness goals and cheering him on at his races. Even though I am not training or competing- so I can put my time into my academics, I feel that triathlon is still a huge part of my life... allowing me to keep on shining.

Miami International Triathlon, March 15th

Greg and I before his race in Miami.

Oceanside 70.3, April 4th

In July, Greg and I are moving to Arizona as I establish my residency and study for the MCATS in order to get into The University of Arizona's Medical School- Phoenix campus. I will be taking the Princeton Review MCAT Prep Course and hope to find a job that strengthens my academics. My advisor suggested not worrying about my medical/volunteer work for my application because it is already so strong, but to start to put more emphasis on my academics instead. Also, most medical schools want applicants to have a passion in something outside of the medical field, which is triathlon for me. With this in mind, academics and triathlon remain top priority for me.

Through my recent experiences with surgery in Bolivia and at the Surgical Training Facility, I am more than ever convinced that my passion is my niche. The next year will be spent on doing whatever it takes to succeed with the balancing act in dreams of becoming a surgeon.

Right Spot, Right Time- Trauma Leg Surgery

2009-04-05T12:47:00.000-07:00

During the last week of my time at Hospital Juan XXIII in La Paz, Bolivia I was beginning to think of taking the rest of the money that I had left over from the fundraiser in San Francisco and donating it to the hospital to do as they felt necessary. Lucky for Trinidad, I was in the right spot at the right time.

I came into the hospital's Trauma surgery department at 8 am and began doing the normal rounds. I was told there was a new patient who was to have surgery that morning. I became excited- only because I loved surgery, and began reviewing the patient's chart as I walked into the patient's room. When I walked into her room, the nurses were already preparing to relocate her to the OR. I introduced myself to Trinidad. As the nurses were trying to transfer her to the OR bed, Trinidad began asking what was going on. She was scared, crying and had no idea what was happening. The nurses began telling her that she was immediately going into surgery. Trinidad looked at me with tears and fear in her eyes and said, I can't pay for the surgery. At that moment, I just knew why I was put in that spot and I told her not to worry. I told her how I was from United States and before coming to Bolivia, people donated money to be able to help people while I was here. I told her that I could give her $100 to pay for the surgery. Unfortunately, that was all the money I had left and it would not cover the full amount of the surgery. The missing amount was close to $20, which she said she could get from her daughter.

Trinidad is a 62 year old lady who weighs 111 kg. Her weight is considered obese and prevented her from being able to walk correctly. A few days before, she fell and landed on her right leg. Due to the fall and lack of proper circulation, the internal bruising began to swell and cause blisters. Trinidad asked her maid to go get some leaves from a plant she owned. She placed the leaves along the shin of her leg and wrapped a bandage around it- a natural medicine cure she had learned during her indigenous life. The next day her leg began to cause her so much pain, she asked the maid to unwrap her leg. After unwrapping the leg, she found it to be worse then it was before and immediately came into the hospital.

Trinidad's surgery consisted of taking off the layer of skin from the anterior frontal compartment of the right leg, then scrapping and cutting through the layers of adipose tissue and muscle to rid of the black, dead tissue that had resulted from the forceful trauma. The leg was left with no skin and required many surgeries to repair- which meant much more money was needed. We covered the open wound with stuff to prevent infection and dressed it in gauze.

I knew that the decision to help Trinidad was right, but I received different opinions from others about it. The plastic surgeon told me that I shouldn't give the money to "the fat lady" and instead should give it to the baby on the 4th floor who had been abandoned by its mother in the hospital. I can understand that the plastic surgeon has had his share of cases where people could not afford the reconstructive surgery necessary and his years of experience has lead him to devise such an opinion about helping those in need. He felt that "the fat lady" was undeserving of the money compared to the abandoned baby. Well, who's to say who is more deserving? I could make an intelligent guess, backed by my experiences to make a decision but my intuition and my heart told me that I was meant to be in that spot at the moment that Trinidad was asking for money. I don't regret my decision and told the surgeon I didn't think of her as "the fat lady" when I made it.

After Trinidad's surgery, I went into her room to see how she was. She was in a lot of pain but happy to see me. Her daughter, Veronica Perez was there by her bedside. Trinidad, who kept calling me "Doctor", could not stop expressing her gratitude. She kept asking my name so she could pray for me everyday. She held my hand and cried. I could barely hold back my own tears but I remained the professional and just smiled back at her. She told me, what goes around comes around... someone will help you out as you've helped me. She was so right, except I knew that I had already been so fortunate in my life. I could recall all the recent acts of kindness from so many special people... Mom, Dad, Frank, Miguel, Thelian just to name a few. Remembering all the acts of kindness that I have been blessed with in my life made me feel that this was just a tiny piece of what I needed to give back. I look forward to being in the right spot at the right time again.

Dressing the wound at the end of the surgery.

Trinidad waiting to come off of the anesthesia after surgery in the OR.

To view graphic photos of the surgery, click here... Trauma Leg Surgery

Hospital Memories

2009-01-22T09:53:00.000-08:00

Anesthesiologist in OR

Casting a 19 day old twin with deformed feet

Clinics in Hospital Juan XXIII

OR in Hospital Juan XXIII

Inivido (Trauma patient with destroyed foot tendons and skin)

Trauma Surgery with Dr. Angulo

Dr. Angulo receiving medication from medical sales rep during clinic, Karen (Trauma Nurse)

Alvaro and Ma. Alejandra (my favorite Surgery Interns)

Antonio (University Volunteer-- 1/1000 diagnosed with Denge), Alejandra (University Nurse), Juanita

Hospital Rounds at 9 pm.

Jorge (Trauma patient- hit by a car, no injuries)

Nurses at Hospital Aymarra

Alvaro (Surgery Intern) and Trauma Nurse

Hip Dysplasia

2009-01-20T14:22:00.000-08:00

Uncommon in United States, half of Dr. Angulo’s clinical patients are referrals from pediatrics to confirm hip dysplasia in babies under 5 months old. Babies after 3 months old are usually referred to an orthopaedic specialist for confirmation that their hips are growing correctly. Hip dysplasia is when the hip bone shifts up and the humeral head shifts out of the socket. The model shows that the yellow part of the humeral head has shifted out of the socket. It can be genetic or formed due to positional circumstances.

It is assumed that babies in Bolivia, and not in other countries, commonly get hip dysplasia because of the way they are positioned during the first few months. The babies are positioned with their legs side by side and wrapped tight in a blanket that goes on the mother’s back to be carried. In this erect position, the baby’s legs are straight, the humeral head faces internally and that forces the hip bones to shift externally. In contrast, American babies are usually carried in the mother’s arms with their legs spread around her side. This position allows the baby’s hips to grow properly because the hip bones are ideally opened up. It is very important to diagnose it as soonas possible to allow repositioning of the hip joint before 5 months, and even more important before 14-16 years old.

When a baby’s x-rays were brought in for review, I measured the hip angle to diagnose hip dysplasia. A line is drawn from the bottom of the pubic arch to the lateral sides of the ishium. This angle must be lessthan 24 cm to be considered healthy. A diagnosis of hip dysplasia is given when the angle is more than 24 cm.

This x-ray shows the left angle at 3o cm and the right angle at 37 cm. A diagnosis for severe hip displaysia.

When the hip is diagnosed early, treatment can correct the deformation. Treatment includes an apparatus (cost is about $11) that holds the femoral bone externally rotated with the legs spread. The apparatus (shown on left) is worn for a minimum of 3 months, 24 hours a day. After the third day, the apparatus can be taken off for 15 minutes to give the baby a shower but must be put on immediately. If the dysplasia is minor, exercises are prescribed. The exercises include moving each hip joint in 10 circles 3 times separately with each side every day until the dysplasia is gone.

Today a 5 month old baby came in and I measured 30 cm on the left hip and 35 cm on the right. In November, the patient was measured at 27 and 27 cm. Within two months the baby had grown hip dysplasia. An apparatus was given to correct the deformity. Another 7 month old came in who had a 38 cm measurement on the right side. Because the baby had gone so long without treatment, the acetabelum had grown a roof (it takes about 11 months to form) and would not allow the humeral head to be pushed back into the socket with treatment alone. In this case, surgery was the only treatment so that the acetabelum could be chipped away at to allow room for movement in the socket.

For most patients living in Bolivia’s indigenous communities, no access to pediatrics, or the Bolivian pediatric doesn’t properly diagnose nor refer thepatient to an orthopaedic specialist, the patient can go undiagnosed and untreated for many years. Going undiagnosed between the ages of 14-16 years old is the most dangerous. Bolivian doctors end up seeing patients who are well into their adult years for hip dysplasia. This is when surgery is the only option.

Hip dysplasia surgery for adults is dangerous and very invasive. If the cartilage in the hip’s acetebelum is still intact, a procedure invented by the Swiss is performed. Most likely, the hip is arthritic. That was probably the primary reason the patient even went to the doctor in the first place, and then happened to get diagnosed with hip dysplasia. When the hip is arthritic, arthroplasty is recommended to replace the arthritic femoral head and acetabelum.

Arthroplasty is very common in United States. 168,000 Americans undergo hip replacement yearly. I have done research and have viewed many hip replacement surgeries by the popular Orthopaedic surgeons (Dr. Bozic, Ries, Jergesen, Vail) at UCSF Medical Center in San Francisco, California. Patients are always pleased and the outcomes are very beneficial for the patient to continue living a normal and active life.

Hip replacement surgery involves making a large lateral incision at the hip, dislocating the hip joint, the femoral head is cut off and then the acetabelum is reamed. A plastic liner is placed in the acetabelum and a metal femoral prothesis is cemented into the hollow hole made in the femoral shaft. Finally a metal ball is attached to the femoral stem and then hip is placed back into the socket.

Last week, my uncle and aunt invited me to have dinner with them at Dr. Cruz’s house. Dr. Cruz and his family are good friends with my mom as well. I was told that Dr. Cruz was as famous in Bolivia as the other Trauma and Orthopaedic surgeon Dr. Zalles from Hospital Juan VVIII, where I was working. He greeted me with a huge hug and immediately started asking me questions. He had to leave for an emergency call but when he came back we talked about, well surgery of course!! He was one of the smartest and friendliest older man that I’d met, which made our conversation so easy.

When he started sharing his new invention for a hip replacement, our conversation just flowed because that was a topic I knew all about. I told him how I worked at The Biomechanical Testing Facility in San Francisco General Hospital. Everything just clicked and we both started scheming how I could help him bring his invention to United States. With a huge smile on his face, he invited me to his office for an interview. That smile plastered on his face the rest of the night was enough motivation for me to go all out with this project.

I went to Dr. Cruz’s office as the first part of the project. He spent an hour explaining his procedure with me. It was something I had pondered about myself so I was very interested. His procedure follows the regular steps for a hip replacement (refer above) up until the plastic liner is placed in the acetabelum. Before the plastic is placed inside, he carves a very special angled triangle into the bone superior to the acetabelum with a special drill saw. He then uses the femoral head bone that was cut off and shapes it to fit like a puzzle into the angled triangle. He either makes the triangle too small or the femoral head piece too big to purposely make a tight fit in order to initiate the like with like rule. Sometimes if the fit is tight enough, he skips using a screw to keep it stabilized. The purpose of this procedure is to make a perfect fitting superior surface for the plastic liner. His theory is that the plastic liner, which can be cemented or screwed into the acetabelum, can move and therefore cause another displacement. Some older patients that grow arthritic hip bones no longer support the screw holding the plastic liner in place and allow the liner to shift, which requires another surgery. Dr. Cruz’s invention has proven to avoid this for hip replacement patients.

Dr. Cruz’s procedure is currently being used by himself and other local surgeons in Bolivia and is titled, “Encastrado de Cruz” (Encased by Cruz). There is another doctor in New Zealand who had invented a procedure similar to his and they are currently competing for the title. Dr. Cruz plans on attending the World Congress Conference in a few months in New Zealand to try to beat his competitor. My plan is to do a research project in San Francisco, demonstrate that the procedure is worthy compared to the original one, publish the article in a medical journal and have Dr. Cruz come work with the surgeons in San Francisco. Seeing his smile again is worth all the work.

To view more photos of the procedure, click here... Dr. Cruz

Hip Fracture Repair Surgery

2009-01-18T23:42:00.000-08:00

A very thin older lady fell on her left hip due to lack of muscle strength and fractured the left iliac crest and pubic crest (refer to CT scan below). Working with a thin body is ideal because there is little tissue (muscle and adipose) to work through. Had I not seen this lady's face, I would have thought she were a child.

Before the surgery, everyone kept remarking how long it would be and how it was going to last the whole morning. I really had no worries because I already knew that hip surgeries are of the longest lasting and require a lot of work. I had observed hip replacement surgeries with Dr. Bozic at UCSF Medical Center, but this was to be my first assisting a hip fracture repair. The team consisted of Dr. Angulo, Dr. Chavez, Dr. Lopez and I. Dr. Angulo came in briefly in the middle so it was Dr. Chavez, Dr. Lopez and I working together for the first part.

We started by disinfecting the entre hip area and then wrapping the patient's hip with a yellow plastic before the incision was made. I waited for the doctor's instructions about how I could be of best assistance. Dr. Chavez was directing and asked me to hold the patient's leg at the knee.

As I was holding the knee, he said, "alto". Alto in spanish is not a command, instead it means either stop or high (as in blood pressure). With the mask covering the doctor's mouth, it was already hard to hear his commands. I didn't know if he was talking to me or the other doctor until Dr. Lopez grabbed my hands and lifted the leg up with me. Then Dr. Chavez shook his head and said, "tonta". Tonta means stupid in spanish.

Later, I confirmed with several people that "alto" doesn't mean lift up, nor is it a command. He's tonto for speaking improper spanish with an American. I paid no attention to his cockiness because I knew he hadn't earned it until he spent his vacations in another country volunteering his medical services. Dr. Lopez, prior to surgery, overheard a conversation I was having with another surgeon about how I have been spending my vacations volunteering and learning about medicine in other countries. As he listened, he was inspired and asked me how he could get into something like that. That day, his inquisitive earned my respect but Dr. Chavez completely lost mine.

The surgery began with an eight inch lateral incision along the left hip. The muscles that are visible once the incision is open are Rectus Femoris, Ilio Tibial Band, Piriformis, Gluteus Minimus and Vastus Lateralis. There are many femoral muscles to cut, grab insertion end with forceps to tag and allow visibility of the femoral head. The Rectus Femoris overlaps the femoral head, which prevents the ability to dislocate the femoral head from the hip's acetabulum. Therefore, the Rectus Femoris is cut and a vertical cut is made through the head of the femur. The bone is cut by hammering into a thinned bottom metal tool (the only tool I don't know the name for). The femoral head is gradually cut through vertically and placed aside with the Rectus Femoris still attached. The hip is then dislocated by forcefully pulling the leg in the opposite direction of the hip's acetabulum once the surrounding muscles have been cut through, no longer allowing their integrity of the hip socket.

Once the hip is dislocated, the pubic crest where the fracture is located. The area of the fractured bone is palpated and drained several times to allow a clean and visible bone to put

the metal plates (refer to left). A bending template is used to measure and predict the shape of the metal plate that will be placed on the bone. A bending iron is used to help mold the bending plate. The metal plate is then chosen according to the length and bended with the bending iron to mimic the bending template. The metal plate is then placed on the bone and with a drill sleeve, a hole is drilled into the bone for the screw. A depth gauge is used to measure the length of the hole in the bone. The length is used to chose the screw and the screw is then hand screwed with a T-handle screwdriver or a regular screwdriver, predicting an angle that won't make the screw come out any of the sides. Oblique angles are usually the best for stability.

Two plates were used on the pubic crest before opening up the superior part of the hip to correct the iliac crest. The fracture was palpated, confirmed with the x-rays and drilled into to place the plate. The wound was then sutured. The bone that was removed from the pubic crest was taken aside and the attached muscle was cleaned off of it. The clean bone was then then placed where it was removed. This procedure follows the surgeon rule: like attaches to like. Muscle will attach to muscle and heal itself that way and the same goes for bone. All the muscles linked with forceps were attached to its insertion with sutures and the muscles that were moved were gradually placed in their proper position.

The periosteal elevator (shown on left) separates periosteum (bone connective tissue) from the bone. This tool was used to scrape the part of the femoral head that was cut before two screws were used to connect the head back together. This procedure follows the like attaches to like rule. When the perioseum is removed from the bone, it helps to initiate the healing process and the bone heals on its own.

The lady stayed awake during the whole surgery and silently prayed. It was the anesthesiologist who told us what she was saying. It was a four hour surgery and you could hear her mumbling the whole time. I enjoyed feeling her stomach move as she breathed when I had my hand against her front pelvis to keep it stabilized during the drilling. Once when I had a hold of her leg to keep the femoral head internally rotated, the whole thing moved while the doctor burnt away at her nerves. These natural reactions were comforting. I was relieved to know I was working on a live person because I've been so used to practicing surgery on cadavers.

The World's Most Dangerous Road

2009-01-18T14:09:00.000-08:00

I went with a group of 17 tourists and 3 guides to the mountain tops in Bolivia called La Cumbre at 4,700 meters above sea level. My uncle Thelian, aunt Beny, and friends: Leonardo, Sylvia and Sylvana followed behind our group in a suv like my camera crew. I began my decent at 9:30 am for 12 miles of paved road for 30 minutes on my haudralic braked mountain bike. The decline was at most 80 km/hr and 34 mph average. This first part of the decline was the safest with wide roads that reminded me of riding in the bay area. We stopped several times along the way to take pictures and make sure everyone was caught up. The picture above shows me at one of our stops with the tourist group's special uniform and dorky helmet on.

The climate changed drastically throughout the decent. It went from freezing cold, due to the altitude, to rainy to windy to hot. I eventually took off my pants and wore my shorts, which made my legs feel so much better after the allergic skin reaction I got. I also felt allot faster with my legs free and feeling more like I was on my bike in the Marin Headlands.

My uncle Padre Thelian Corona (above with video camera) chased after us in car with video camera in hand. Every time the group stopped, he jumped out of the car and filmed the group, narrating each detail of the adventure.

Someone from the group told me, I'm not sure who's having more fun, your uncle or you. My uncle and I are still arguing that one out. Watching him film me doing what I love to do was one of the most enjoyable things about my adventure and he was happy to be apart of what I loved to do. At least I know I burned more calories then him.

The second decent for about 20 miles was the part known as the "Most Dangerous Road in the World". There is an old path that cars and buses used a few years ago that displays crosses along the side of the road representing the hundreds that have died. They most recently built a new road where the cars and buses now drive and can cross more safely. We took the old road, staying on the left (part of the rules-- the left is the clift side?!) and the cars stayed behind us. Sometimes my family and friends drove right behind me and filmed me cycling until I passed people and got too ahead of them for them to follow. I had no idea they were behind me until I saw the video later. The road consisted of rocky, steep roads and views of beautiful green covered mountains and waterfalls fresh from the day's rain. It was my first time mountain biking but I got used to it fast and spent the last miles of the decline racing my male competitors.

After 30 miles and a decline from 15,158 feet to 3,636 feet, we stopped in a tropical town called Coroico to jump in the cold pool and enjoy an indoor buffet. I was lucky to have my friends and family with me to enjoy the long decline. We all happily ate pico de gallo Corona style and enjoyed the Bolivian beer. We left around 4pm, drove into the town of Coroico and then drove 3 hours home uphill in the rain.

Emergency Foot Surgery

2009-01-16T04:16:00.000-08:00

A ten year old boy came into the emergency room at 8:30 am because a machine ran over his foot. I spent the morning with him in the emergency room until we rushed him into surgery at 10 am with Dr. Angulo. After given anesthesia to numb him from the belly button down, we began to clean the open womb with disinfectant (refer to photo above). All the red is the disinfectant.

The womb was open on the top of the foot from the end of the toes to the bottom of the ankle. The skin was gone from the bottom of the ankle half way down the open wound. This was the biggest problem presented. The next problem was that about 6 inches of the tendons, going from the ankle into the foot were destroyed. There was no way to correct the tendons that extend the toes and foot. Therefore, the boy would keep his foot but would never be able to flex it (the photo shows the boy's foot in the extended position-- I'm the one in the light scrubs on the left). This wouldn’t stop him from walking, but he won’t walk correctly. The skin must be corrected with plastic surgery, which will require an estimated six more surgeries to correct.

We spent about two hours cleaning the wound. The tissue and tendons were black from burnt and dirt. The black tendons were cut and the womb was drained several times. I’ve never seen so much blood loss before. The boy was lucky to have kept the integrity of his foot and still have it intact. At the end of surgery, there wasn’t enough skin at the ankle area to close it so gauze, soaked in disinfectant was used to cover the womb. Near the toes, there was enough skin to suture the skin closed. The only risk until his surgery in three days is to avoid infection to his open wounds.

The picture above shows the anatomy of the muscles and tendons of the foot. The four long and very superficial Extensor Digitorium Longus tendons were destroyed along with the skin that covered them.

Working with Dr. Angulo is always a pleasure. He even invited the boy's mother into the operating room to show and explain the gravity of the injury. He is referred to by most patients as shy and they say he doesn’t look you in the eyes. Every time I greet him in the morning, he kisses my cheek and shakes my hand. He treats me with respect and speaks to me like a friend. I enjoy his company and believe he is a good surgeon. I love how he says, “aha?” after every sentence and mamasita (mom) and reina (queen) to all the women. It’s a mannerism that is very comforting. He is the kind of surgeon that I’d like to mimic.

To view more photos of the surgery, click here... Foot Surgery Album

Fractured Ulnar-Radial Repair

2009-01-15T18:00:00.000-08:00

During my first day in Hospital Juan VVIII in La Paz, Bolivia, I spent the morning with Dr. Chavez and Dr. Angulo, surgeons in Trauma and Orthopaedics. Arriving at 9am after rounds, we rushed into surgery at 9:30. I was accompanied by a forth year medical student, Maria Alejandra and Dr. Angulo.

Scrubbing into a Bolivian surgery was somewhat different from what I have experienced at University of San Francisco Medical Center with the Orthopaedic surgeons. First, I entered the OR (operating room) with their special scrubs and asked for gloves. Everyone going into the OR in the U.S. wears gloves as part of a sterile procedure. The OR staff looked at me weird and didn’t answer. I had to ask several times until they told me that only the people who scrubbed in wore gloves. When Dr. Angulo entered the room, he asked me to scrub in so I did finally get the chance to wear the gloves.

The process of scrubbing in was the same as in the U.S. You wash your hands using a scrub brush all the way up to your elbows with a dark special disinfectant for ten minutes. In the U.S, we have a pedal to kick to turn off and on the water so you don’t infect yourself after your wash. In Bolivia, I had to use the faucet handle, that only gave cold water, after disinfecting my hands which made no sense for sterilization. Then, making sure you don’t touch anything with your hands, you enter the OR’s swinging doors. Keeping your hands up in the air with bent elbows, you wait for your turn as the OR staff dresses you with the robe that only ties from the back and opens your gloves to slip your hands through. I learned how to prepare for sterile dressing while observing Orthopaedic surgeries and at The Surgical Training Facility. I’ve had experience scrubbing in a surgery before, but not assisting hands-on. This was to be my first experience assisting a surgery.

The patient was a 44 year old women with a severe 2 week old distal, oblique ulnar-radial fracture on her left forearm, usually caused by a twisting force. When we entered the OR, the patient was already out via general anesthesia. The surgeon began by cleaning the skin and the other medical student and I draped the patient, leaving only the left forearm visible. The surgeon made the incision about 8 inches long on the ulnar side. As we assisted by using certain tools to hold back the tissue and skin, the surgeon cut through the adipose tissue, muscle and into the ligaments to find the fractured bones, making sure to avoid the ulnar nerve. The displayed x-rays hanging above were a good guide to how long and where the fractures were (I had a picture of hers but it got erased, the x-ray on left is an example but not a distal-oblique fracture such as the patients). The three of us worked as a team, I helped the surgeon keep the displaying bones blood free with the vacuum, holding back the tissue with bone retractors to allow sufficient views, meeting the surgeon’s scissors with the metal burner to burn through the tissue and anticipating his every move and need.

While working as a team, there are times where you have the responsibility to do everything at least once, except use the Bolivian home drill and hand screwdriver. One time, I was asked to go to the opposite side of the surgeon, reaching over the patient to pull two bone retractors with force. Since Dr. Angulo was tall, so was the table and the staff pushed over a stool for me to stand on so I could reach over the patient. The stool was so tall that they had it on its side. The challenge was that the side wood boards were ¼ the size of the bottom of my shoe. I was balancing like that for hours and expected to pull, push and all with stability. There came a time where I almost lost my balance because I was reaching too far to one side and I reached down with one of my hands to balance myself on my leg. Dr. Chavez, who came in minutes before, yelled at me to keep my sterile gloves on the surgical table. Then he asked, where are you from? That’s the number one rule through out the world. Did they not teach you that in United States? I didn’t say anything to him. Actually they hadn’t specifically taught me that rule in the U.S. but I wasn’t going to say anything bad about the country I represented. What I wanted to say was my country would have never handed me a stool such as to assist in a surgery!

Once the fracture was found on the ulnar side, a metal plate with 8 holes was drilled into the bone and the same procedure was done on the radial side. Both incisions, ¾ the size of the forearm were closed, wrapped with cotton, a cast was placed on the bottom part of the arm and finally wrapped with gauze. I noticed how fast the closure and post-op was done because the patient was starting to wake up and wouldn’t stop moving. The speed resulted in a sloppy job. Sloppy for me as a perfectionist—like leaving cotton hanging out of the cast.

Cholecystectomy and Appendectomy Surgery

2009-01-15T15:00:00.000-08:00

(left to right) Appendix, Gallbladder with 6cm wall and several stones inside

Dr. Ochoa, a Bolivian internal medicine surgeon who wears sunglasses and smokes while seeing his patients has roughly ¾ of them in for vesicle stone issues. Gallbladder stones are very rare in the United States and other parts of the world. Bolivia has the most gallbladder cancer cases in the world caused by a diet full of fats. Cancer is formed when the stones are not removed and cause a growth of the internal muscle wall of the vesicle and surrounding canal or stomach. The large muscle wall of the gallbladder is suppose to be 1 cm in width but can be found to be as big as 6 cm in most Bolivian patients (as seen in the patient above). CAT scans are used to view the gallbladder and stones. The only cases that require surgical removal by fluoroscopy or open surgery is when the patient is complaining of pain and has a limited diet due to the stones.

White fluorophosphates stones are formed when there is an increased amount of fats from pig, milk products, eggs, and most every indigenous Bolivian food. When these types of foods are consumed, the body releases bile (a yellowish alkaline liquid helping to digest fats in the duodenum of the large intestine and stored in the pancreas) from the liver into the surrounding ducts and into the attached gallbladder. The bile inside the gallbladder rushes into the gallbladder opening and causes movement of the stones inside. Movement of the stones inside the gallbladder cause irritation to the large muscle wall and the wall gradually grows. This irritation is very dangerous and with an incretion of the gallbladder wall comes a greater risk of cancer. The movement of bile continues into the canal attaching the gallbladder to the duodenum of the large intestine and can cause the stones to be pushed out of the gallbladder’s sphincters and can get stuck in them or find its way out and into the canal. When the stones reach the canal, this causes a clog of bile and bile is pushed back into the gallbladder or ducts. The gallbladder releases a normal amount of 800-1,200 liters of bile a day, any more then that and it can assist in the cause for cancer. If the bile is stuck inside the gallbladder, the fats don’t get digested in the large intestine as well. This danger is easily diagnosed with visible yellow eyes.

Appendectomy is always accompanied by gallbladder removal surgery because it always proves to cause a problem eventually for Dr. Ochoa's patients. The appendix is involved with the immune system. It is a long tube of tissue attached to the cecum end of the large intestine. It is removed with gallbladder removal or in Appendicitis. Appendicitis is hard to diagnose because the pain is not localized to the area of location, but instead around the whole stomach. Elevation of white blood cell counts and normal urine tests are ways to diagnose appendicitis.

There are two types of gallbladder removal surgeries. The first is a laparoscopic approach. Three laparoscopic ports are used: a 10-mm port at the infra-umbilicus, a 5-mm midline port 5 cm above the symphysis pubis, and a 10-mm port that was two-thirds of the way along the
line from the umbilicus to the left anterior iliac crest. A Bolivian doctor claims to have invented the three-hole approach versus four. This is a very non-invasive approach yet costs $3,000. The second type is open surgery. This type is more commonly used by Dr. Ochoa because of the accompanied Appendectomy. The cost for this is $2,400 (they actually use dollars to announce the price).

While working with Dr. Ochoa in the afternoon in the surgery department, I got the chance to assist in this procedure. The older female patient was brought in for gallbladder removal and appendectomy. She was placed in the Trendelenburg position with feet higher than head to allow gravity to pull intestines away from pelvis. Under general anesthesia, a 2 -3 inch incision was made in her right lower abdomen. The gallbladder is found under several layers deep into the abdomen. An incision is made at the gallbladder end that connects with the canal and removed. Stones outside the gallbladder are removed as well, and the canal is sutured.

Then the appendix is freed from its attachment to the abdomen and the colon by cutting the thick muscle tissue that attaches the appendix to the colon, being careful not to cut the appendix wall. The hole is sewn over by making two insertions with a needle in the cecum and then into the end with the hole and knotting it together. This makes the open end tuck itself into the cecum. Abscess (pus) is then drained out with a rubber tube from a hole made through the skin a few inches lower then the incision. The layers of fat, muscle and skin are then closed and the patient goes home in one to two days if the precautions and treatment are followed correctly.

Infection or scars can occur inside the incision because of the depth. Scars eventually go away and are palpated near the incision by a hardness, whereas the rest of the stomach is soft. Infection can require another surgery at its worst. Removal of the appendix has not shown to have any effects on children nor adults, but some studies show that it can cause a slight increase of diseases such as Crohn’s Disease. Overall, this procedure is recommended when the stones cause pain for the patient but it is never forced. Since most of the people in Bolivia are poor, the cost is the number one reason for holding off on the surgery. In this case, this patient is given special instructions to avoid a diet with fat and some medication to help push the stones back into the gallbladder. Pushing the stones back into the gallbladder isn't the cure and can actually cause more pain when the bile is released into the gallbladder again because it moves them around the wall, causing irritation and growth. Then they return back to the spot they once were. Surgery is highly recommended, as there is no cure, even though natural medicine doctors in Bolivia prescribe olive oil and lime.

Dr. Ochoa ended the two hour surgery explaining that the surgeon is the leader of the surgery but that the anesthesiologist is the one that the surgery can’t go without. I’ve been in a surgery where the patient said that their knee hurt during a knee replacement and another one where a lady in Bolivia silently prayed for the three hour hip surgery... one can only hope they can't feel whats going on. Dr. Ochoa also explained the importance of the surgeon to always come into the OR with a clear head. That he should never bring his worries from home to work.

After giving a lecture about the importance of surgery, we rushed out of the OR with a tin holding the appendix, gallbladder and stones. Dr. Ochoa invited all the patient’s family into a small room to explain the importance of the surgery and to open the gallbladder to show the stones inside (refer to picture below).

About 10 family members entered the small room and the doctor revealed one of the worse cases of stones and the danger of the width that the gallbladder wall had grown to have. The gallbladder was taken to the laboratory for cancer tests and the white stones were offered to the family.

Making History

2009-01-14T21:15:00.000-08:00

Machu Picchu 2005 (Anja Strehlow)

Machu Picchu 2009 (Anisia Garcia Corona)

Machu Picchu 1977 (Bill Garcia and Sylvia Corona)

In 1977, when my mom my was also 28, my parents left behind my older sister Afra of one years old with the family in Mexico to go to
Machu Picchu, Peru. They stood at the edge of the cementery
overlooking Machu Picchu to take a picture. Even
though the picture shows the depth of their marriage
at that time, it has always been the only photo I've
had of the two of them together... and what a photo it
is! It was my goal to make history and be in the same
spot where my parents once walked together with such a

beautiful view. As well as the place where my best friend sent me a

postcard from four years prior. On January 5th, I set out on my
adventure to Machu Picchu.

My first attempt to enter Peru was denied because
they wouldn’t allow me into Peru without a Visa for my
Mexican passport. I got as far as the border, 2 hours
away from the city of La Paz, and turned around. At
the border, two girls on the bus, who happen to be
studying at Arizona State University asked me why I
wasn’t crying that I had to go home. I told them
because I knew I would be back. With the help of the
staff at the University, especially Alejandra and
Leonardo, I went to the Peruvian consolate and got the
necessary paperwork needed for the Visa. 4 days later,
with passport in hand, I set out on my goal once
again.

Alejandra’s youngest brother, Darwin greeted my
arrival in Cusco. He showed me around Cusco at night.
With the streetlights shining on the old Incan rock at
night, Cusco reminded me of the small European town
Firenze, Italia. The streets were clean and the
organization was obvious. Police guards even patrolled
the callejones, paved with flat marble stone. My hotel room
had a balcony view of the center of town. Within the first
couple minutes of getting to know Cusco, I was already
wishing I had a Visa for Peru longer than five days.

I took a train on Day 2 to Aguascalientes, a town
located on the bottom of Machu Picchu. From there, a
bus took us a half an hour up winding dirt roads to
the top where Machu Picchu could be seen at 2,000 feet
above sea level. The community of Machu Picchu was
built by the Incan community several hundreds of years
ago and has to this day left historians in the dark
about its history. It is thought of as one of the Lost
Cities.

After getting a tour of the ruins, I jogged down the
declined steps for about an hour to reach the town of
AguasCalientes. I found Alejandra’s oldest brother, a
4th year medical student at an Argentinan school, at
an Internet café in the center of town. Alejandra’s
mother cordially invited me to eat and drink at the nearby
restaurant. We all talked as I waited for my train
departure back to Cusco. AguasCalientes is a place of
paradise for me. The river runs through the town,
adding sounds of forceful waterfalls. It is encased
in the tall, green Peruivan mountains that are also
the views from Machu Picchu… a sight I knew would
bring me back one day.

Visiting Machu Picchu was about being apart of my parent's history.

Physiology of High Altitudes

2009-01-08T11:51:00.000-08:00

There are many physiological changes that occur with higher altitudes. Since I've been living at 4,000 meters above sea level for over 2 weeks, I've felt them all and more so the past couple days. First, we require more food intake at higher altitudes because our work efficiency decreases (Journal of Nutrition). When altitude increases immediately, heart rate increases but it lowers as you keep getting higher and then levels off at a higher heart rate then resting until you go back down to sea level (Journal of Nutrition). Since altitude reduces oxygen supply to cells, supplementations of fish oil and Vitamin E are recommended to reduce symptoms. Fish oil has already shown to have benefits with cardiovascular diseases by increasing oxygen levels specifically in muscle cells (PubMed) and that's why it works well with high altitudes. Here are some of the effects and training/nutrition recommendations of high altitudes...

Immediate effects:

- Increased breathing rate/heart rate [Even when sitting- totally sucks]

- Nausea & headache [Headache is felt in the occipital part of skull]

- Giddiness

- Sleepiness [I've even fallen asleep while talking and have to take naps everyday]

- Decrease in Vo2 max

- Swelling feet and fingers

Long term effects:

- Increased erythrocite volume

- Increased haemoglobin volume and concentration

- Increased blood viscosity, increased capillarisation

- Continued lower Vo2 max (5-7%/ 1,000 meters)

- Decreased lactic acid tolerance

- Reduced stroke volume

Training:

Some studies have shown that the benefits of training short term at high altitude can be offset by the limitations of it. The limitations that I've come across are access to running paths, facilities, diet and surroundings. The benefits of training in altitude don't even peak until the 19th and 21st day and then between the 36th and 48th day after returning to sea level. Overall, the benefits of high altitude training can lead to overtraining and offset any positive outcomes from altitude training.

Through studies of altitude, the term live high-train low was developed. Endurance athletes slept at 2,500 meters above sea level and then trained at sea level. This improved their sea level performances overall and that's why so many endurance athletes try this.

The problem with high altitude training relies in the fact that one is not able to maintain high intensity training and in turn, overall aerobic fitness declines. In high altitude, resting and submaximal heart rate decreases overtime due to acclimation but still remains higher then at sea level. Contrary to that, during maximal effort exercise at high altitude, heart rate decreases or remains the same as at sea level. Because of these physiological changes with heart rate in high altitude, sea level training standards can not be used ie: heart rate level ranges. Live high-train low can work if the standard heart rate ranges aren't used.

Another problem with high altitude training is the dryness of the air which causes an increase in water loss through breathing and an overall increase in dehydration. Women have a change in hormones and release of metabolites due to acclimation changes, which can effect performance and increase urine frequency. There is also an increase in ultraviolet rays at high altitude causing sunburn and dehydration. Water supplementation is recommended to alleviate any more symptoms.

Altitude does equal less air resistance hence, an advantage for speed work. As well as a change in the force of gravity, involving an advantage in relative and maximum strength.

Nutrition:

- Energy metabolism decreases (wemjournal)

- Increase amounts of carbohydrates due to decreased oxygen levels [Easy to find in a South American diet]

- Increase amounts of iron due to decreased red blood cells [I suggest iron in supplementation]

- Vitamins to assist in suppression of immunity

- Simple is better, prevent overeating to allow proper digestion [Studies show that altitude doesn't decrease digestion time]

- Avoid dairy [Soy products are very popular in South America]

- Vegetable diet recommended to get nutrients and assist digestion in high altitudes

Inevitable Outcomes of Birth and Death

2009-01-06T14:33:00.000-08:00

I mentioned in "Rules in Medicine" that sometimes a doctor can only do so much to save a patient. Already, I have come to believe that death is not clinical. I believe it has as much to do with fate as it does in birth. There have been many clinical cases where even when all the hospital staff sees no going forward with saving the patient, the doctor's decision is to keep going in case there may be a chance. Is the outcome inevitable despite the continuous efforts of the hospital staff?

I have not clinically nor personally experienced the dying of a human being, but I have with my dog Bubu. I came home to my house on the lake one night in 2001 to be greeted by my dog at my car door. Although that day, he did not have the strength to jump onto my lap the minute I opened the car door like he normally had. That day he followed me as I carried my hands full of things inside the house. Almost into the house, I turned around and saw Bubu's body swaying back and forth behind me. I ran inside, freed my hands and ran back outside to see Bubu on the floor-- flat. I picked him up, he was dead weight and it scared me. I laid him on the floor in the living room. I was so scared of his dead weight that I didn't want to touch him. It was then that I remembered that there was a vet down the street from my house so I attempted to take him there. When I walked outside with him in my arms, my neighbor had pulled up just in time. I got in his car and he drove me with Bubu in my arms to the vet. He peed on the way to the vet and when I got there, they pronounced him dead. There's a long story about his cause of death that I won't go into because it involves blood and bites... a cause that as of today my answer is ridiculed by the unbelievers [If you're interested, I'd be glad to tell you the story so you can make your own opinions].

I watched Bubu die. At the time, I was so scared of his dead weight and unsure of the truth in it, that I didn't watch his last breath. The only thing we can solidify is that he was to die that day but despite his inevitable death, he waited till the very last moment for me to get home so that I would be there when it happened. He choose to die in my arms and that was his fate. I couldn't have been happier about that, but of course I still grieved to accept he was no longer in my life.

A very special inevitable outcome in my life involves both birth and death. I have been blessed to grow up with an identical twin sister, Teana and a triplet sister, Sara. Through my passion for the study of genetics, I have come to discover that Sara and I have more physical attributes in common then compared to Teana. Physical attributes including things such as height, weight and bone girth. Teana, Sara and I are triplets. We all look alike in every way except Sara's sexy freckles and skin color, light brown hair and to die for blue eyes. Besides those things, when we walk into a place we are asked right away if we are sisters. Most ask if Sara and Teana are the twins.

The amazing thing about nature vs. nurture is that Sara does not share the same biological parents that Teana and I do. But the three of us have grown up sharing the same crib, mother's nipple, morals and values, education, sports, practically everything. The three of us triplets are the closest friends we have and I mean that in every physical and mental way.

Sara being brought into my life was pure fate. Learning about death, I have come to realize how important it is to accept that fate. This personal, yet clinical story makes it easier for me to do just that...

Arleen was brought into the delivery room at night with Sara in her stomach because she was slightly bleeding. Sara was her second pregnancy besides recently having had an abortion. Soon after starting dilation, her uterus ruptured in a line that can be traced back to that of an abortion incision. Dr. Forbes explains that in a case such as this, there is nothing that can be done. The amniotic fluid from the uterus, fetal cells and the urethan blood had already reached her lungs and cardiovascular system. Her blood could no longer clot and she bled uncontrollably from the previous uterus incision line. Arleen died and Sara was born. Dr. Forbes says that this is one of the obstetric disasters that no one has any control over and every obstetrician dreads in their career. In this case, I am not on the clinical side so it's easier to see it as fate. Although Arleen died, it was an inevitable outcome that I have Sara in my life.

The Wonders of Evolution

2009-01-04T07:59:00.000-08:00

The science of genetics has created a way as to preserve the strongest, those who have built traits allowing him to survive, and has allowed them to reproduce as well. This idea is taken from both Darwin's Theory of Evolution and the ideas from Richard Dawkin's The Selfish Gene Theory (The Selfish Gene is one of my favorite books). Darwin's theory believes that genes are a blueprint for a trait that benefit an organism, whereas Dawkin's theory goes a little further to believe that the genes are created only to benefit themsleves, hense selfish. Either theory explains how traits are mutated along the lifeline and why the strongest that survive have certain traits.

Living amongst the indigenous people of Escoma, Bolivia (Imarra) has allowed me to see these theories at work. The Imarra have certain traits that allow them not only to survive in the conditions of Escoma but to reproduce, be successful and be happy. It took my first glance at an Imarran women to feel a sense of pity for her. Then I stepped back... she was not only alive, but she had a baby on her back and a smile on her face. Then I looked even closer at her. She had just come in from slaving outside in the fields since 5 am, her house was made of adobe mud, she had several kids at home that she had given birth to on her own and raised to work as hard as she did. This woman was so strong... she could carry a huge wrap with a baby in it and hold an amazing amount of strength for whatever her medical condition was. Although her skin was wrinkled and her feet hard, those traits that I thought were to pity kept her alive.

The Imarra people have lived this way for years. They have adapted to the hot weather during the day while working in the fields and the cold weather they experience year round. They make their houses out of the adobe mud, which helps keep them out of the harsh winds at night coming from the lake and altitude. They use a hole with a basket as their toilet and wash ther clothes in the nearby running streams [the government once donated tons of toilets and when they came back, the Imarrans had used them for holding the potatoes]. They wake up as soon as the sun comes up, start working in the fields and are inside before the sun goes down to remain warm.

The Imarrans eat dehydrated potatoes, drink trimate and a special type of corn. I refered to dehydrated potatoes in "A Bolivian Diet". Trimate is a tea obtained from anise, camomile flowers and coca leaves. It works best to sooth stomach aches, helps digestion of food and alleviate symptoms of altitude by oxygenating the body. This diet allows them to stay strong and healthy. Most Bolivians think this is the secret (they must not know about the law of attraction). If the Imarrans can live to be so strong and healthy, eating these three things as their staple, why can't we all eat these and be as strong as the Imarra? Thats a good question... if we mimiced the Imarra diet, could we be as strong as the Imarra? I predict since we don't mimic their everyday life and most importantly, their genes, we could not.

I take my own experiences livng in Escoma as an example. I have my own genes that have allowed me to live and stay strong in the North American lifestyle. I have an immunity and evolutionary stable strategy already set by my genes. During my stay in Escoma, my body was not comfortable with eating just meat and potatoes. I was scared for my survival (really) when the cook only made soups of pig fat, potatoes, fried food and boiled corn. All of this was served with bread and warm mate tea. With the genes that I've adapted to survive, this diet would not make me stronger.

My immune system could not adapt to this lifestyle. I came down with a foot fungus and a mild eye irritation (actually still haven't been able to correctly diagnose the eye issue). Since there is no need for a doctors prescription, I was able to go into the pharmacy in La Paz and easily get what I needed. They gave me a fungus cream that cost six dollars. It is to be used 1-3 times a day for 2-4 weeks. I also got some eye drops, one free from Hospital Aymara and the other for three dollars at the pharmacy when the other didn't reduce symptoms. Neither have worked to reduce the redness in the interior part of my eyes. I would not diagnose it as an infection because of the lack of eye discharge and think it may have something to do with the altitude. I have prescribed myself nothing other than mate tea with ibuprofin to help with the increased blood pressure and sometimes shortness of breath, in hopes that if the eye symptoms are from altitude they will go away.

Geneticists have a way of answering the question: which came first, the chicken or the egg? A: The chicken is the eggs way of making more eggs. The Imarrans have adapted to such a hard lifestyle and have proven to become stronger and reproduce over many years. I am good example as to what would happen should United States decide to go to war with the Imarrans. Even should I try to live in Escoma for a longer period of time, my survival genes would mutate to allow my survival, but I would never be as strong as the Imarra. I dont pity them at all.

Physical Activity in Escoma

2009-01-02T09:54:00.000-08:00

Walking miles and miles through the fields of Escoma... I encountered hard-working women, cows, sheep and unfriendly dogs.

Dancing during a wedding celebration.

View of the Lake Titicaca Triathlon start... would you believe I won the triathlon. The water was

a comfortable temperature with my wetsuit, which allowed me to swim faster then everyone else.

The pool in the town of Aguascalientes (Hot Water). The pool charges less than .50 cents/hour to enter. The water comes from underground pipes originating from volcanic land. The temperature stays around 85 degrees F. I went in hopes to get some swimming in... not quite what I expected. I was the only female with a bathingsuit on (my speedo of course) while the men wore swim shorts.

Riding a borrowed bike outside of Escoma. Few cars passed on the road but I had to ride against traffic. The cars ride in the middle of both lanes and honk like mad going 100 km/hr when they see someone on the road.

Rules in Medicine

2008-12-30T13:39:00.000-08:00

Rule: Don't let things snowball because when the bigger snowball hits later, it will be a lot harder.

I took the day off from the hospital yesterday to take care of myself. I have been living under certain conditions that I knew could eventually lead to a decline in my health. Although I was on a mission to help others, I knew it was important to help myself first. First thing was exercise: lowers blood pressure, increases oxygen levels, provides blood flow, increases the "feel good" hormone and builds muscle strength in core and stabilizing muscles to maintain a healthy posture and withstand fatigue. I spent four hours testing the strength of my lungs and using other parts of my brain by climbing the mountains behind Escoma. I was super duper happy amongst all the natural beauty, I couldn't help but dance to all my favorite songs playing on my ipod. I was glad that nobody saw me, but who cares cause now it's no secret :) Second thing was eating healthy: providing myself with the necessary vitamins and minerals for a sufficient immune system and desired body composition. I sent one of the doctors going to La Paz's market place for some fruits and vegetables and laid out my daily supplements (multi, TJ's veggie plus, fiber tablets and dried fruit). I also began my food diary to increase my awareness and promote healthy eating from all of the necessary food groups. Third thing was mental health: review the past, let it go and make plans and goals for the future. All the emotional experiences at the hospital and with one of the doctors had become a little overwhelming for me. I needed to learn to start acting like a doctor and not a medical student which meant not internalizing all of my experiences, something I was going to have to consciously learn to do.

When I returned to the hospital, I was greeted with many welcomes. I was given the feeling that I was missed by the amount of attention and concern. The doctor who I had felt a little uncomfortable working with immediately apologized, presented his most humanistic side and transfered into my teacher and friend. Even the cleaning lady noticed I had not been there the day before and stopped to ask me how I was. It was something of fate for her to have asked me because her and I sat in the sun and talked for awhile. I got to know many things about her and her about me. She told me about how she came in either in the afternoon or morning to clean while her husband worked in the hospital as well. She rented a place close to the hospital where she lived with her two kids, Olivia and Viral. Her sister cared for the two while she was at work. This lady was pleasant, very conversational and inquisitive. It was a gift to have had the chance to talk to her. Having a day to take care of myself definitely put me ahead where had I ignored it, it would have come back to bite me harder.

Rule: You must heal yourself to be available to heal others.

There's a rule in the medical field (as it should relate to any field) that you can heal others only if you have healed yourself. I have always felt strong about this saying and picked it up more when I was in the fitness industry. When I worked as a personal trainer, teaching others to live a healthier life by exercising and eating according to their needs, I encountered many co-workers that did not abide by this common-sense rule. There was a time when a fellow personal trainer who graduated with a Masters in nutrition asked me to help her loose some weight. A compliment to me, but I questioned her responsibility for her own well-being. I always thought that her clientele might feel the same way. She was actually the trainer who had the most clientele. Would you trust someone who looks overweight to help you loose weight? I looked into that topic for a long time. I read a study about the credibility of a coach who wasn't any good at a sport, yet was able to coach a winning team. The study showed that even when a coach's skills are never achieved, the coach is still able to overall have a successful winning team. Reasons for these results lie in the fact that skill is only a piece of the pie in order to coach successfully a winning team. In regards to the rule, your health is not the only factor in the healing of others but it is a piece of the pie on the path to being more successful.

A priest asked me over dinner if I would ever come back to work here when I become a doctor. Due to a certain destined event, it was easy for me to say no. I had the chance to hear and see what one of the doctors was experiencing on an emotional level while working here. He had volunteered to come to Bolivia from Cuba and work here for two years. Unaware of where he was being sent, he agreed. Once in Bolivia, his fate was the small town of Escoma. He loved his profession so much, had he been born again he would choose the same, he did not complain. I could easily diagnose the good looking, once sociable and happy doctor as depressed and more sadly, very lonely. He explained how after work all he could do was go home, watch movies, listen to his Cuban music or fiddle on the computer without internet access. He also explained his many unsuccessful attempts to become more than friends with the very unfriendly Bolivian women. If given the opportunity to work as a doctor anywhere unknown around the world for a few years, I would not do it even if I was married or had a family. I am too aware of what that fate might lead to thanks to this doctor. I only hope that he can cure himself to continue giving what he came to give to the town of Escoma.

Rule: Sometimes we need someone else to help us do for ourselves what we already know how to do.

Even more reason to always be there for others, even when they don't request your help or appear that they have and know it all.

Rule: To carry out a healthy 40 weeks of pregnancy, a mother should visit her Gynecologist for regular check-ups.

I spent the day with the 34 year old Cuban Gynecologist, Fernando. A 34 year old lady who was 24 weeks pregnant came in for her check up. She wasn't having any pain or problems with her pregnancy. The doctor showed me how to do the exam and allowed me to mimic his procedures. We had her lie face up on an examination table. Her stomach was palpated in search of the spine and head. The spine was apparent by the hardness of the area. The head was palpated by using two hands to feel an indention on both sides and also a hardness of the area. The head was found to be at the pelvis end of the stomach, which was only to be of concern if the lady was closer to the 40th week of pregnancy (40 weeks is the max for caring out the pregnancy but usually never the case). The baby's heartbeat was found using a warmed up metal tube placed on the location of the spine area. The heartbeat can only be heard on the spine side because since the baby is usually in the fetal position, all the extremities hide the heart from the front. It was exciting to hear the soft bump, bump of a baby's heart.

The pregnant mommy was then taken into the ultrasound room. She laid on the table face up and ultrasound gel was placed all over the stomach. During the ultrasound, several things were distinguished. First the oval shaped head was found. It is the easiest thing to distinguish in an ultrasound because of the position, size and shape. The size from the top view of one occipital lobe to the other was measured. The measurement on the ultrasound machine then categorized the size and displayed that it was at 24 weeks, which shows that the baby is a perfect size for its age. Then the abdomen size was measured from the belly button to the spine from a lateral view. The femur and humerus bones were the most distinguishable at this age, but only the femur was measured. Then the sex was determined and it was exciting to tell the lady for the first time that she was having a girl. The organs such as the heart and stomach were also visible at that age. The two most important things that were determined in the ultrasound were the two lateral ventricles that later become the brain and the amniotic fluid inside the placenta that was easily distinguished by its dark color that surrounded the baby's body. The baby girl showed to be healthy and the patient was told to come back for the pregnancy and check ups prior to the 40th week.

Rule: Becoming pregnant after the age of 36 is a high-risk.

Another 39 year old pregnant lady of 32 weeks came in with her husband due to pain in the upper stomach. Fernando reminded her not to be working in the fields, something he always found himself doing working with this community. It was fortunate that the lady's husband was there because she said she had and the only way to get her to stop would be to tell her husband. Bolivian women are objects to the males and often do all of the farm work, even when they are five weeks away from birth such as in this case. She was examined in the same way. The ultrasound showed more organs at this stage, such as the kidneys. When the doctor suggested for the best of her and her baby's health she remain in the hospital until the pains go away, she refused. It was important to have a mother such as herself stay in the hospital because of all the things against her: her age, still working in the fields, her fifth child and the fact that her last home birth left her five-day old baby dead.

Becoming pregnant older than the age of 36 is a high-risk event. There are many complications that occur with the pregnancy. Complications from birth are usually never the cause of death but the pregnancy is. High blood pressure and diabetes are of the most dangerous events. The cause for most issues is the cause of hormonal invasions and an amniocentesis is important to check the amniotic fluid for these hormones. The body is capable of turning the helpful hormones needed for the mother's own growth, as well as the baby's into self-destroying toxins. These toxins eventually eat away at the placenta and the only cure is to rid of the placenta and baby. In this case, the placenta which is the most important part of birth, can become its own reason for death. There are many complications that occur with a mother older than 36 years so it is important that she care for herself and the baby even more.

Rule: When something is bleeding, remove whatever it is from the body.

Sometimes removing the placenta and baby in the case above.

Rule: There are some events where the doctor has the power to do something to keep the patient alive, and there are some events where the doctor doesn't have the power to keep the patient alive. One must distinguish each event, but do everything in their power at all times until so.

I have come to realize that being an endurance athlete has helped me transfer the tricks I've learned to keep focused and moving no matter what into an attitude for enduring fatigue in the hospital.

Rule: Practice not only makes perfect when becoming a doctor, but it also helps to numb instinctive responses.

Which is good reason for sticking it through this month in Bolivia.

Lake Titicaca's Beautiful Views

2008-12-29T12:29:00.000-08:00

(click to enlarge photos)

Hiking in high altitude over mountain tops to Lake Titicaca. You can't see the huge smile on my face, but I'm pretty happy to finally be exercising after a few days of sedentary acclimation to the altitude. The sign of an acclimation problem is coughing up blood- not for an endurance athlete!

The highest mountain behind Escoma that I climbed up and over... notice how close the clouds are. They move very fast and the winds pick up at that height.

Visiting Lake Titicaca just outside the town of Escoma after a day of work in the hospital. Lake Titicaca is the highest lake in the world, sitting at 11,463 ft. It is one of the five biggest lakes in the world, but biggest in South America. It runs 196 km (122 mi.) long and 56 km (35 mi.) wide from Peru to Bolivia. Don't bother asking a Peruvian or a Bolivian which side -"titi" or "caca"- resides on.

A Bolivian Diet

2008-12-29T02:45:00.000-08:00

Being a poor country, Bolivians choose a diet mainly of meats and breads. Meats are usually boiled in soups or cooked over the stove with seasonings.

Here are some potatoes, cucumbers, carrots and tomatoes. There are many different types of potatoes here and they are served at lunch and dinner. I tried dehydrated potatoes the other day in my soup. They are purple and have been left out to dry so that they can be stored for a longer period of time without going bad. The taste is very bland.

These are some beans being sold in the market. Bolivians eat every type of bean, adding them to their meat soups.

This is a poster posted up in Hospital Aymara. It shows the basic diet for a healthy Bolivian... meats, carrots, potatoes, papaya, mango, beans, oranges, green leafs and grains.

The most common type of bread eaten with every meal.

When a Bolivian is desperate...

2008-12-28T17:06:00.000-08:00

(Warning: a bit depressing)

When a Bolivian traveler is desperate...

he will fit into a van just to get somewhere. A van ride to the city of La Paz costs 12 Bolivian cents (around a dollar and some cents). Although cheap, the three hour ride means squeezing into a van with more than the 15 max.

When a Bolivian farm worker is desperate...

she will come to the market place in the center of town on Sunday and sell the cow she just killed. She will cut the meat, laying open on the floor for her customer.

When a Bolivian child is desperate...

for something to do, he swallows a coin while playing with it. An eight year old boy came into the clinic to remove a coin (see x-ray below) he had swallowed yesterday while playing!? Removal of a coin in the esophagus is done using a machine that has a long tube inserted into the throat with a light and camera on the other end while a wire with a clasp on the end is inserted down the tube. This procedure took four of us to do, the surgeon, a Cuban gynecologist, a Cuban radiologist and me. I was in charge of opening and closing the wire clasps once the coin was in sight through the camera that the radiologist was viewing through. The surgeon, Marco and gynecologist, Antonio had a hold of the boy from the head and hands. The boy entered the room and from the beginning it was obvious that he was not willing to cooperate. The Cubans, showing off, began messing around with the kid. Their aggressive attitude towards the kid only made him timid and non-responsive. They even started saying things like, make sure you behave like a man for that pretty women over there (referring to me). Marco calmly interrupted the two Cuban doctors' aggressive behavior and asked the boy his name. Although he remained quiet with a look of fear on his face, he was more responsive to Marco's calm behavior then the two Cuban show-offs.

The procedure began by laying the boy on his left side. The tube with the light and microscope was then inserted down his throat. As one can imagine, this was not a comfortable procedure for the boy. He struggled with us and coughed forcefully. We had to invite his mother in the room to help us relax him. She sat at his feet and translated in Imara (the indigenous language) what we were saying. Once we finally got the tube down his throat, I inserted the wire. The procedure was to find the coin using the microscope and position the wired clasps on the edge of the coin and pull it out. Not that easy. We all have a natural gag reflex in our throat. This natural reflex is stimulated when our throats and esophagus become irritated, inflamed or filled with mucus. All these symptoms occur when there is a tube placed down the throat and moved around. Every time we found the coin and had a grasp of it, the boy would cough, cry out loud or move. Every time this would move the coin and we would start the procedure all over again. This repetitive scenario occurred over and over again for five hours.

During the five hours, everyone in the room was tested. The boy would have sporadic crying fits where he would try to remove the mouth piece or cough it out. The Cuban doctor using the microscope would forcefully yell things like don't move, be a man, what a big thing it was, how stupid was he to swallow the coin... a lot of don'ts and negatives. There were many times where he even grabbed the boy's face or hit his arm. He stayed very attentive, being that he had the most important job. He took maybe two breaks to move his arms that had been holding up the microscope but did tell the other Cuban doctor that he was about to cry. There were a few times that he turned to me and asked me if I was tired and I replied, I'm fine thank you- how are you doing? He replied with a wink. He would break the silence by turning to me and joke around like saying, it's only been 15 minutes right? His mom sat at his feet and would translate soft-spokenly what we were yelling at him. There was only one time where she lightly tapped his butt, after seeing one of the Cuban doctors hit him. Marco, the surgeon sat at his side and held his hands down so he wouldn't try to remove the mouth piece. Marco was kind and gentle. He would gently rub his side and held his hands in comfort, even stroking them at times. He did hit him once on the butt but his voice was soft and kind as he told him to stop crying. Most of the time he was quiet, never showing any sign of impatience. The Cuban gynecologist stood at the boy's head and held the tube into his throat. He was in an uncomfortable position at the end of the table where his neck had to be flexed forward and ducked under a cabinet. He moved around often trying to find a comfortable position for his neck. He only became forceful by pushing the boy's head into the table when he began to move and cry hysterically.

Since my job was to hold the wire up as steady as possible at eye level and push and pull the handle that was the end of the wire clasp, I only had to worry about my arms and hands fatiguing. One time a doctor saw my hands shake and said I was nervous. I had to explain that my deltoid was fatiguing and I repositioned the handle in my hands, lowered my arms to my side, tightened my abs and contracted my rhomboids. The only time I opened my mouth to contribute to the doctors' yelling was to softly tell the boy to relax and breathe through his nose every time he would cough and move the coin, making us start all over again. I only got frustrated when the doctor with the microscope would tell me to turn the wire "this way" or "that way". I had to tell him several times that I only understood "right" or "left". I tried to be the calmest in the room, hoping that the others would take notice and mimic me. It took repeating positive commands and remembering moments in my life where I was happy- plenty of fresh ones to get me through the five hours.

After an exhausting five hours of unsuccessful intentions to remove the coin that had moved all the way down into the stomach, the boy's resistance to a huge amount of an alcohol type injection and constant coughing and crying fits, we called it quits. Because of the lack of an anesthesiologist at Hospital Aymara, the decision was to send the boy to La Paz where a more forceful machine and anesthesia could be used. Frustrated and tired, we stopped the procedure and everyone left the room. The scared and tired boy got up from the table with spit and blood all over him. I was the only one who thought to even attend to the patient. I grabbed some towels and wiped him off as the doctors yelled at him. I'm sure the kid will remember this forever and the sad thing is that it was not over. I am paying for the ambulance ride and any other costs that they will come across in La Paz for the procedure. I was told that it shouldn't be that much but I thought it was a good cause since he had already put up with five hours of pain for what turned out to be unsuccessful and frustrating for everyone in the end.

When a Bolivian medical student is desperate...

they rely on live dogs for practicing surgical procedures. The students roam La Paz's center of town in search of live dogs. The dogs are given anesthesia and used for practice with intestinal repairs or repairing fractures. The medical students will cut the large intestine and repair it as well as break bones to repair the fractures. Of course, the dogs never live through the surgeries. Why would the Bolivians care, they probably carried some type of disease or would die on the streets soon anyways.

When a Bolivian family is desperate...

for money, they will sell their kid's organs for as much as $20,000 by placing an ad in the local newspaper. They will also disobey the doctor's order to keep a fatal patient in the hospital where he can be cured and take him home where he usually dies. They will also make such decisions about further treatment regarding their child with themselves in mind... usually leading to death of one of many children. They tend not to show any remorse about the fatal decision they've made because they say that they have many other children at home.

Shots of Life In Bolivia

2008-12-28T16:57:00.000-08:00

A couple outside attending to their store.

A worker attending to her sheep near Lake Titicaca.

The view while entering the city of Escoma.

Lake Titicaca's calm waters that nearly touch the clouds.

A group of dancers during the Sunday festival in the center of town.

God Must Be Bolivian

2008-12-27T09:13:00.000-08:00

A surgeon's day at Hospital Aymara starts at 8 am Monday-Saturdays and 7:30 am on Sundays. There is a break at noon where everyone eats and then goes home to return at 2-5 pm. The first hours are spent consulting the in-house patients and confirming plans for their future. Marco, the 32 year old surgeon at Hospital Amyara spent the morning reviewing the status of each patient with me. Most of the patients were in-house due to diseases uncommon in the states. Many, I couldn't even find a translation for. Marco and I spent the day sitting around sharing stories, curriculum and ideas. Typical for the life in Escoma, we spent most of the time just sitting on a bench outside. We talked the whole time, but most Bolivians that shared the same pass time just sat there. Although young, it was apparent that Marco was a good doctor and had a solid education. He was making plans to leave Escoma for Brazil in a few months and eventually go into cardiothoracic surgery.

Operating Room at Hospital Aymara

Emergency Room at Hospital Aymara

The Bolivian medical path consists of three years of study and three years of working rounds in the hospital. With the completion of this, a general medicine license is given and the specialty residency begins. Surgical residency is three years. The Bolivian residency is very different from that of the states. The licensed doctors are allowed to gradually start the hands-on surgery with live patients. Third year surgeons in the states are lucky to use the hammer or suture at the end of their surgery rotation. Most Bolivian surgeons learn hands-on and eventually become very comfortable with the procedures right away. Marco explained to me that the cheaper public medical schools were even better then the more expensive private schools because of the ability to have more hands-on experiences. The fact that Marco was a resident, working at the hospital as the only surgeon, proved that the Bolivian curriculum made for a more experienced surgeon.

With the Bolivian people being so traditional in old habits and skeptical to learning the new ways of life, the medicine of today is looked down upon. If one has chest pain, they drink mate tea. If the chest pain returns, they go get medication which doesn't require a prescription for. Only leaving going to the doctor the last resort. Usually treatment can be solved when diagnosis is determined right away. In such a case with medical treatment being a last resort, the treatment is usually very difficult and can be fatal. If treatment is not an option and the patient is untreatable, the hospital's reputation only worsens. This is the story 99% of the time. When I asked one of the older priests had he ever visited Hospital Aymara, he said proudly- never. He said he didn't like hospitals. During dinner, I asked another younger priest student if he liked Hospital Aymara, he also replied no. Since the Escoma community has such an old fashion attitude towards their health, hospital visits continue to be a last resort.

The hospital serves a free breakfast and lunch to employees. Breakfast, made by the cook, is served in the kitchen and is available at any time. The director told me to start my Saturday by coming in at 8 and that I would find breakfast there in the hospital. Breakfast consists of tea or coffee and bread (a french, or in spanish- bolio). When I was given my options of plain bread or plain bread, I was happy that I had grabbed a banana on the way out. I ate the bread and sipped what was a dark, timid tea. Lunch was served at noon in the kitchen for the employees, which included the surgeon, nurse, and radiologist. We were served a vegetable soup with some type of thin grain. When I requested a big amount of soup, the surgeon told me that women there ate smaller amounts of soup. Then I was served a huge plate of white rice and a few scoops of meat with lentils and carrots. I asked for a less amount of this, being that the soup was already enough for me but the cook insisted on piling my plate. The other female doctors weren't shy with portions of this and even cleaned their plates faster then me. It's obvious that people prefer the rice and meat to soup. I on the other hand prefer the soup.

A younger lady had fractured her right femur, had a long screw inserted vertically down the femoral canal with a horizontal screw placed mid way and later got an infection. The infection caused an inflammation inside the bone at the location of the horizontal screw and after being closed, it spread all the way down the femoral shaft. The surgery was performed in La Paz and was left to be treated in Escoma. Prior to today, there had been many attempts of healing the infection at the location of the screw by opening at the place of incision and cleaning it out. It had been infected again today and the patient was in to remove more infection. I had the pleasure of watching the surgeon stick gauze into the quarter size open incision with pickups while the lady cried out loud. Unlike the surgery I have seen and performed on cadavers, this was a live person with no anesthesia feeling every movement. Blood and tissue flooded out of the wound as the surgeon poked and turned the gauze internally what seemed to be more than twenty times. It wasn't the blood that I couldn't handle, but the cries of the lady as each gauze was inserted and twisted inside her thigh. Maybe it was because I was already having back pain due to the amazing sleeping accommodations, or that I had eaten lunch only a few minutes prior or because it was my first open wound cleaning observation, but for the first time I had to remove my layers of clothing and when that didn't work, leave the room before I acted on what I felt the need to do. That strong lady got up a few minutes later, grabbed her crutches and hopped out with a smile on her face. I was amazed at her strength.

Later an old lady came in for her check-up after having been bitten by a cow yesterday. The cow took off half of the pointer finger of her left hand. It had fractured the finger bone half way down and it was surgically removed and sutured closed. The check up was to confirm that the sutures had not opened and to clean the finger to prevent any infection. Infection seemed bound to happen by the look of the rest of her hands. The hands and finger nails looked as though they hadn't been washed in weeks- covered in dirt and blood. The bandages were removed and her half-sized finger was revealed. Only a stub remained from what should have been her nail. The lady was so calm and quiet as the surgeon cleaned the stub. After re-wrapping it with gauze and athletic tape, he asked her to clean the rest of her hands and not to hit the finger on anything to avoid breaking the sutures. She was asked to return in 4 days as long as there was no pain. Only God knows how she plans on continuing to work in the fields and keep the wrapped finger safe.

Another older lady, with what was the scariest face I have seen, came in crying. As the bandage was taken off, the reason was revealed. A 3rd degree wound the size of a peanut butter jar top lay on the internal side of her left forearm. The wound revealed tissue and muscle since there was no superficial nor internal layers of skin to cover it. She had been bitten by a dog. As the surgeon cleaned and dabbed at the wound, the lady didn't stop talking in her own language and silently let out tears as she looked my way to wipe them off. I gave her a smile as she looked at me looking at her. Before the nurse re-wrapped her, she asked her if she had the dressing they had given her. She told the nurse, to get it from her wrap laying on the floor by her feet. As the nurse leaned down and opened the wrap, she quickly yelled and jumped back. The old lady, acting calm and non-surprised, leaned down and revealed what was a dead mouse in her wrap. She picked the mouse up and laid it on the other side of the wrap to grab the dressing. As the surgeon and I laughed, the nurse sat on the other side of the room calming herself down and the old lady kept talking to us in her own language as though explaining herself. The nurse translated that she had just stepped on the mouse to bring it to her cat at home. Un-sanitary acts like that makes one wonder how this lady was going to be able to keep her open wound clean for the 3-4 months it would take to close. With Bolivian people like that, one must wonder; is God Bolivian?

New World, New Type of Medicine

2008-12-26T12:30:00.000-08:00

It’s the day after Christmas and I have left the city of La Paz, Bolivia for Escoma. La Paz is the bowl shaped capital of Bolivia. Bolivia consists of 10 different regions, with only a few of them considered cities. La Paz is a bowl surrounded by a wall of beautiful white, sharp mountains. These mountains don’t go to waist and are covered with colored houses, commonly made of a brick type material. These houses hang off the sides of the mountains which create inclines and declines that nobody would ever believe cars travel on. Last night four of us squeezed into a five-person car on our way home from dinner. We had to leave one person on the side of the road and return later to be able to make it up the inclined road where one's house was. Most of the city streets are rough which ruin automatic cars so everyone drives stick. There are NO rules when driving, which highlights the Bolivian motto: He who is stronger wins. Everyone pushes their way through. I Iearned that even if it means pushing aside a lady such as myself.

About 90% of the population is indigenous, very short in stature and dark skinned. The women here are not as powerful as any man and would not believe I did sports. Most of the indigenous women and children roaming the streets only come at this time of year to beg for money. Some women even borrowed children from others to look more needy.

Dr. Carla and I outside the University Salesiana Bolivia on Christmas Day.

I was invited to have Christmas Eve dinner and Christmas dinner with Dr. Carla and her family. The ambiance was calm, yet conversational. Everyone was curious and very friendly. Everyone knew my uncle Dr. Padre Argeo Thelian Corona Cortez and spoke about how he changed the community where the University was since he arrived from Rome five years ago. They also spoke well of my mom and aunt Beny, always emphasizing what an amazing lady my mom is. I was quick to agree.

A driver named Leonardo who works for my uncle at the University and his wife Sylvia, a lawyer drove me three hours, past Lake Titicaca to the small town of Escoma. I was so excited to be out of the city and in a place where there was water since I brought my wetsuit, dirt paths and hills to run on without being afraid of getting lost. We arrived in the town of Escoma and drove through the streets in search of Hospital Aymara. When we pulled over to ask a young girl where the hospital was, she shyly walked away and finally answered over there. We found it in the center of town.

A kid riding a bike way too big for him in the center of town-- had me laughing.

I met with Dominico, a young Italian medical director for the hospital. He was fair skinned, skinny, tall, with bright blue eyes and a very fresh face. He wore a wedding ring, jersey with jeans and a jacket. I was very impressed to see such a man living in Escoma. After introducing himself to me, he led me through the small hospital and into his office. He pulled a seat over for me and asked me how old I was. I answered, 28 and he sat at his desk facing me repeating it several times. He then told me that after receiving all the paperwork I had sent, which included my resume and curriculum, he had a few questions that would determine my success there. He wanted to confirm that I had indeed had a background in rehab/physical therapy. He said he was concerned because there wasn’t any rehab work in Escoma. I had to explain to him that I was entering the medical field after working in the rehab field for five years. Once we cleared the problem and he learned my preferred specialty of surgery, he introduced me to the young surgeon whom I would be working with.

I was then given a tour of the hospital and explained that during the holidays and new year, the people spent time in their houses drinking and the hospital would be very slow. During my tour, it was obvious that there were few people in at a given time... one bench seat in the waiting hallway and one to two beds in each of the patient rooms. There were a few hundred more patient file folders then people in Escoma due to others coming from as far away as ten hours for medical service. Dominico briefly showed me the equipment each department had but explained that it was not always used. The type of medicine that Bolivians mostly use is from the head. He compared it to how people who use calculators can no longer calculate in their head. He suggests that what makes for a good doctor is intelligence and the ability to be flexible when treating. Knowing emergency medicine is a good example. Most medics who get caught in route and only have a certain amount of tools at hand can come up with sufficient treatment while most doctors depend too much on technology. This explanation made my reason for learning other types of medicine in the world even more important.

My First Lesson In Medicine

2008-12-25T17:16:00.000-08:00

Dying. Death. Defining these words have become my first lesson in medicine. The difference between these words has been highlighted even more as I enter the world of medicine. Who would think, after all medicine is a profession where the goal is to prolong a life. Over the past few months, I have had the chance to confront, distinguish and ultimately depersonalize myself from these words.

In June 2008, I began what would be part of my destined introduction into the world of surgery. I had no idea that death would become a constant in my life. Fate led me to check the inbox for an old email address where I found an invitation. I had been invited by Dr. Richard Caughlin and Dr. Anthony Luke to a cadaver lab. Dr. Caughlin and Dr. Luke, leaders of the UCSF Trauma and Orthopaedics Department, organized continuing education for volunteers at the ODC Dance Clinics Rehab department and UCSF Sports Medicine events. This cadaver lab, which costs several hundreds of dollars for the department, was part of the continuing education that we received for volunteering.

The cadaver lab allowed each of us to have a lower leg cut below the knee and several hours to dissect it as we pleased. In the medical field, we believe that knowing a cadaver in everyway is the path to overcome injury or death. We were offered the opportunity to work with a lower leg because while working in the dance clinic and medicine tents, we saw many injuries that occured at the foot and ankle. The foot can be a very lengthy process to dissect due to all the tendons involved with movement of the toes and ankle. I shared a sense of humanity with what was my first personal cadaver as I began removing the superficial layer of skin. I even named my lower leg (shown on the surgery table below) and diagnosed her as though she were a live patient. It was a coping mechanism for something that seemed so inhumane.

The location for the cadaver lab was The Surgical Training Facility at San Francisco General Hospital. The Surgical Training Facility (STF) is funded by the University of San Francisco Medical Center (UCSF). Built in September 2007, its primary goal was to have a high-end facility where residents, surgeons and medical sales reps could practice and teach surgical procedures. The facility is equipped with the most modern surgical tables, tools, lights, and everything else used in hospital operating rooms. The companies hold all-day seminars inviting surgeons to perform, learn or/and teach how to use their newest medical devices or/and procedures on cadavers.

I am quick to read myself when I am introduced to something I want in my life and I am not afraid to take risks to have it. Walking into STF, I knew I was in my zone- similar to how I feel about riding my bike. The love of dissection seperates a surgeon from the rest of the world. Not all medical students can stomach what is the dead. I knew my place right away. I approached the manager and asked if they were hiring. When I returned from my medical mission in Costa Rica and Panama, I was hired.

For many medical students, getting the opportunity to work with cadavers is something that happens in the later part of medical school. Ive been told that the hidden truth about the hardest thing in medical school is being comfortable with death, not all the memorization. Everyone has a different reaction to death. The process of dying is emotional because its something that occurs with the living as well as the person dying. Death is whats physiologically left over when the soul no longer occupies the body. Physiological events occur and can be best understood through science. As Aristole says, nature does nothing uselessly. Death can only be appreciated when these physiological events are seen as part of the life cycle.

A Bolivian priest working in the University of Don Bosco in La Paz believes that life has been given to us, we dont have the right to make a decision as to how to end it. He believes that everything has a reason. For example, the Bolivian people live a poor life. To try to change this would be going against what is part of the reason for their existence. This idea is parallel to changing the path of death. We are not given the right to make such decisions.

Going through the process of donating your body, writing your will and obtaining life insurance are all ways to prepare for your death. People who are healthy and mentally stable can sign their body away to UCSFs Willed Body Program (WBP). The contract states that they have to be mentally healthy during the signing and that their body will go to medical studies. No specifics are given as to which type of study, although there is a range of things that one can do with a cadaver. Once the donor dies, the body goes to WBP for harvesting (a term they use instead of dismembering) and distribution. The distribution is not cheap, with certain body parts costing as much as thousands of dollars.

Depersonalizing a cadaver presented to me cut in half, with all its organs removed and no limbs, has helped me seperate the meaning of the two words dying and death. Neither knowing the cadaver as a living human, nor watching the actual dying has allowed my use of the dead for scientic purposes more justifiable. My future in this field will introduce me to death during dissection, resuscitation and the prouncement of it. Medical school curriculum teaches doctors to supress or suspend any human feelings for death. In opposition, I plan on placing more emphasis on providing comfort instead of curing, which involves not avoiding difficult patient conversations or determining final treatment for a terminal patient. My decision may be challenged but I stand in question of the norm. I have yet to learn which can really make for a better doctor.

The Gift of Giving

2008-12-21T07:54:00.000-08:00

"There is a wonderful mythical law of nature that the three things we crave most in life-- happiness, freedom, and peace of mind-- are always attained by giving them to someone else." – Peyton Conway March 

I hosted a casual bar fundraiser at The Gravity in San Francisco’s Marina district Saturday, December 20th. Several of my friends came out to support my mission and were generous in giving warm clothing and money. I raised $146 and received several bags of clothing. The money is being used to buy over the counter medications and personalized things for the Bolivian community. I will be sharing the details about how I spend the money in later posts. I am very thankful to all my friends who came to give. 

"No person has ever been honored for what he received. He is honored for what he gave." - Calvin Coolidge

My best friend Anja gave me one of the best personalized gifts for Christmas. Giving with the knowledge of what the other person really needs is what makes you feel kinda "superhuman"-- That's why I plan on using the donated money for personalized gifts. I'm lucky to have a friend who knows me so well. I'm happy to know I'll have the perfect read for me on my trip... Final Exam-- A Surgeon's Reflections on Mortality

One of my favorite children's books is Shel Silverstone's-- The Giving Tree. It is about a boy and a tree that become best friends. The tree always provides the boy with what he wants... branches to swing from, apples to eat, and shade. As the boy grows older, he requires different things from the tree... branches to build a house. In the ultimate act of self-sacrifice, the tree lets him cut him down to build a boat in which he can retire and sail away in. The boy leaves the tree as a stump. As an old man, he returns to the tree. The tree tells the old man, I have nothing to give you. The old man replies that he does have what he needs... a quiet place to sit and rest.

"You can't have a perfect day without doing something for someone who'll never be able to repay you. - John Wooden

Via South America

2008-12-17T20:32:00.000-08:00

“Adventure is a path. Real adventure (self-determined, self-motivated, often risky) forces you to have first-hand encounters with the world. The world the way it is, not the way you imagine it. Your body will collide with the earth and you will bear witness. In this way you will be compelled to grapple with the limitless kindness and bottomless cruelty of humankind and perhaps realize that you yourself are capable of both. This will change you. Nothing will ever again be black and white.” - Mark Jenkins.

Classes are over and yet I return to my normal routine… sitting at The Grove in San Francisco's Marina district reading or writing. This is so natural for me. Only this time, I get to choose what I want to focus on, not Organic Chemistry or Calculus!

I leave for South America in a few days. I will be spending three weeks at Hospital Aymara in Escoma, Bolivia and two weeks at Hospital Juan XXII in La Paz, Bolivia working with Sports Medicine Dr. Zalles and General Medicine Dr. Aparicio. I have had many angels working for me to make this happen. My uncle Thelian, a Selesian priest working in La Paz, Bolivia has helped make this trip successful. My mom and aunt Beny have guided me to Bolivia through their stories of the doctors and amazing medical service they received in Hospital Juan XXII while on vacation. I have much to be thankful for and without the guidance of these special people in my life, I would not have made the decision to work in South America.

As I prepare for my medical mission in Bolivia, I am feeling excited and anxious to go into another world. I enjoy learning new cultures and learning what other people in the world do to be happy. Life without all the electronics and material things that I have can be challenging but not impossible. I really, really enjoy having my Blackberry on me at all times. Can I let that go, yes I can. Although when I do have it, I really do appreciate it-- that’s what’s important.

I have all that I need to be happy. I don’t really have to worry about what I need for this trip… I have my integrity, soul and faith. Soul was one of the things that I learned to always maintain. Last medical mission in Costa Rica, I met an older lady in the neighborhood clinic we had. She told me something that I will never forget--- When she was diagnosed with a reading disorder, I offered her the opportunity to purchase the necessary reading glasses that we were selling for $5.00. This lady looked at me and leaned in close to say, I can’t even afford $5.00. I only get $20.00/month... I lost it. My emotions took over and I had to excuse myself from the room and asked someone else to take over. I went into the bathroom and cried. I cried for all the older ladies in this world like her. Women like my mom, my aunts and what could be me. I cried for this lady. I couldn’t forget the way she looked at me and told me her story—I will never forget it. Even today, I am forced to remember her when I am faced with a challenge in my life. I compare my story to hers and I lose all victim feelings I have.

My emotions became so intense; like someone crossing the finish line at the Ironman World Championships in Hawaii, I had to leave the clinic. I stood outside and looked at the neighborhood. The level of poverty was so obvious. Drug dealers roamed around and every door was surrounded with gates. My boss, Edwin joined me outside. We had gotten to know each other pretty well the first day I arrived to Costa Rica. I was the first one of twelve to arrive and had alone time with Edwin for several hours—we talked about everything. Edwin was a Costa Rican native who worked with adolescents. He was not in the medical field but had worked with aspiring medical students like me and in the clinics for several years. He had an outside view of what serving people in the medical field was. He stood with me and let me cry. When I apologized for my unprofessionalism, he told me not to ever forget my human emotions when I practiced as a doctor.

A friend once asked me what my biggest fear was, I answered losing faith. It's amazing to see what provides faith for people from different countries. I have faith that whatever is suppose to happen, will happen. I plan to honor my integrity, my word to serve the Bolivian people with all that I have learned through all my years of practicing in physical therapy, athletic training, coaching and in the medical field. I will be patient and focused, keeping others first.

I am entering South America as a Mexican citizen. I established my dual citizenship December 12^th, 2008 @ 12:00. Having a mother who was born in Mexico allowed me to establish dual citizenship. Since it is harder to enter South America as an American with a visa, I decided to establish the dual citizenship. I am entering South America with my new Mexican Passport and my birth name.

This mission will create many pictures and stories. Packed with a new MacBook and camera, you will have the opportunity to see my perfect world.

Water Please!

2008-08-10T20:57:00.001-07:00

Preparing for a ½ Ironman event has brought up a whole new set of responsibilities. It is important that an athlete participating in an exercise event lasting over three hours knows how to determine what they need to make the best decision about hydration.

I completed my first ½ Ironman Duathlon event in Oregon and will be completing a full 1/2 in Santa Cruz and Arizona. The responsibility of knowing everything about hydration can determine a lot in one’s race with a change in environment. I did my research and put it to test. I had very good results in Oregon and am confident in sharing it in hopes that others will have as much success! Photo courtesy of Peter McIntosh

Physiology of Dehydration:

During exercise our core temperature rises due to energy being released during the internal breakdown of glycogen stored in the muscles and liver, along with some protein, fat and blood glucose from recently ingested food (although it takes several hours for our body to fully digest recent food to be able to use as energy). It’s your body’s goal to maintain homeostasis at a temperature of 96.8 [degrees] F.

The body’s cooling system allows heat loss through the skin when hot blood from the core is carried through the capillaries to the skin’s pores and therefore releasing the heat. You also breathe out heat with each increased breath. 75% of the body’s cooling system is the ability to produce and excrete sweat. Sweat alone does not cool, it must be evaporated. It works because as the water molecule of hot sweat lies on your skin, it is evaporated into the gas phase. This conversion of liquid phase to gas phase requires energy (or more heat) so as it changes form, it takes on a hotter condition off your skin than on your skin making your skin cooler than it was before.

When racing in hot temperatures with a little breeze, you rely on evaporate cooling. In conditions like Kona, Hawaii where there is no breeze, your body still relies on evaporation and you need to sweat more to stay cool in these conditions. When racing in colder conditions, if your body reaches 95 [degrees] F, you start to absorb heat instead of losing it. Evaporate cooling is all that’s left to cool the body.

In humidity like Arizona, sweat can’t evaporate at the same rate because the atmosphere is already saturated with water vapor. Sweat accumulates but doesn’t give any cooling effects. In these conditions, you may be soaking wet but it is not cooling you off. Photo courtesy of Peter McIntosh

In the worst of conditions, you can produce 3 liters of sweat/hr of strenuous exercise. Your body can only absorb 1 liter/hr.

Thirsty sensation means you have already lost 2% of body weight. That is the maximum about of body weight you want to lose.

Core body temperature has been shown to rise an additional 0.15-0.2 [degrees]C for every 1% of bodyweight lost to dehydration during exercise.

Pre-Race Hydration:

500 ml (2 cups) before bed
500 ml (2 cups) wake up
500 – 1000 ml (2-4 cups) 1 hour prior to event
Total of 24-30 oz 20 min before event

250 – 500 ml (1-2 cups) * 20 min before event

* Electrolytes may be used for all the other times except 20 min before event

During-Race Hydration:

150–250 ml / 4-10 oz / 1/2–1 cup / 3 big gulps every 15-20 min
500-750 ml /16-24 oz* every hour
*over 28 oz/hr. leads to hyponatremia

Hydration during an event (1/2 Ironman or Ironman) should be supplemented with sodium. It helps to restore electrolytes and energy due prolonged sweating and consuming high doses of water. Electrolytes are chemicals that form electrically charged ions in body fluids. These ions are important for the carrying the electrical energy for nerve impulse and muscle contraction. That’s why without these, you began to feel fatigue and nausea. No cases have been reported of death, only DNF.

Cytomax contains 150 mg sodium/16 oz
Gatorade contains 220 mg sodium/16 oz

Salt tablets are not acceptable forms of electrolyte replacements because they only provide two electrolytes (sodium and chloride) out of the total necessary for your body to function and they can also over supply sodium.

Dehydration Tests:

1. Nail color: If you put pressure with your thumb on any of your finger nails and the color returns immediately, the test for dehydration is negative. If the darker color takes longer than usual to return back to normal then the test is positive for dehydration. This is something that can be done while exercising.

2. Skin: If you grab a pinch of skin with your thumb and pointer finger from the top of either hand and let it go, the skin should immediately return back to its normal position on the hand. If the skin immediately returns, the test for dehydration is negative. If the skin takes a while to return back to the hand, the test is positive for dehydration.

3. Urine: If it runs pale yellow, the test is negative for dehydration. If it runs dark yellow, the test is positive for dehydration. Your body's cells are taking in all the ingested liquid to continue working.

* If the test for dehydration is positive, rehydrate correctly and moderately. If you consume too much water, the stomach won't absorb it all at once and it leads to bloating, nausea and indigestion.

Determining Sodium Needs:

Individuals have different sweating rates that vary with intensity and temperature. The body does not efficiently replace what it expends during exercise at any intensity. The body only replaces 35-45% (fluids, calories and electrolytes) of what it loses during exercise.

Weigh yourself without shoes or clothes, and record it, noting temperature and humidity.

Workout for one hour.

Dry off and weigh yourself, recording the weight lost and any fluids you consumed while exercising.

Use the following formula to determine your hydration needs:

One pound lost = 16 ounces of fluid/hour of exercise (for that type, temperature and intensity)

Ex: If you lost two pounds/hour, you replenish 32 ounces of fluid (about 8 ounces every 15 minutes) in the same conditions.

Do this test a few times in different conditions to get a sense of how your hydration needs change in varying temperatures, humidity and intensity levels.

Online calculator available @ powerbar.com/hydration

Hyponatremia:

Hyponatremia is caused when your fluid-intake is so high that you dilute the sodium content of your blood. "I personally think it's purely a size effect. Women are more likely to develop a fluid overload simply because it takes less fluid for smaller people to become overloaded," says Lewis G. Maharam, M.D., the medical director for the Rock 'N' Roll marathons and the ING New York City Marathon. Consuming over 28 oz of plain water/hr of high intensity or exercising for periods longer than 6 hrs can be the main contributors.

This condition usually occurs in mid or slower paced athletes then top ranked athletes. This is usually because the top ranked athletes tend not to stop at aid stations and are not exercising for such a long time, unlike the mid to slower athletes. Stopping at aid stations means usually over-hydrating and being slower means more time spent hydrating. Do the recommended calculations for your body and don’t second guess yourself when you see the aid station with water and cookies.

Another factor for hyponatremia is increased amounts of NAIDS pre-race. The problem is the inability of the athlete to excrete the excess fluid because of high levels of fluid-retaining hormones ADH and AVF." NSAIDs (non-steroidal anti-inflammatory medications) decrease blood flow to the kidneys, thereby increasing ADH and AVF.

To help with hyponatremia pre-race, you can add sodium to your pre-workout/race meals to increase your electrolytes. Also avoid drinking more than usual during race week. This will dilute your blood sodium levels, putting you at higher risk of developing hyponatremia. Remember that your fluid needs drop during taper week. Drink normal amounts of fluid.

Cool-Down Tips:

In order to get the body's internal core to lower, you can stop for a few minutes at the water stops or lightly spin on the bike. Cool the core by drinking cold water and allowing the internal body heat to dissipate outside... then resume. You can request sponges and ice at the water stops to insert into your clothing.

Use the water hose to cover your skin and clothes. This way of cooling only works in an environment where there is enough breeze to evaporate the water from your surface. Otherwise, you are just more wet then before... and a little heavier.

Photo taken at Full Vineman August 1, 2008. This guy was first place overall. The second place guy came more than 10 minutes later to this water stop. The water stop was at the 6 mile marker of the marathon in an Ironman.

Wear white or other light colors. Avoid wearing black on your clothes or hat.

Use a glycerol solution (ex: Liquids End) up to 3 days prior to store water in your body for race day. Water is taken in by the body's cells with any ingested carbohydrates. This will lead to gain in weight though.

Los Ninos

2008-08-09T22:23:00.000-07:00

There’s a title for children in Costa Rica: Latin victim. This title was introduced to me the first day upon my arrival. It means that latin children grow up feeling as if the world owes them something, that they are victim to the world and if they want something- beg for it. Unfortunately the children grow up only knowing and practicing this way of life… leading to a lack of self-motivation as an adult.

I noticed how beautiful each and every nino was. Every single one! Most of the ninas were well groomed with pig tails, dresses and smiles. The ninos were just as adorable and well groomed. Same for the babies, they all had a sparkle in their eyes and beautiful dark features. I can’t say that for most babies and children I come across in the states.

I feel that it’s the opposite for adults. Adults in Central America appear older then they are, less groomed and signs of mal nutrition. This is a consequence for growing up as a latin victim.

An 8 year old named Henedy came in with his mom. His mother explained that Henedy was born with an unusual condition. He was born with his heart and organs on the opposite side of his body. His heart was on the right side of his sternum… I confirmed with my stethoscope and heard the heart beat. He also had Type 1 Diabetes that he had under control. Before the mother could began to explain why she had come into the clinic, she asked Henedy to find a place on the other side of the room. Once Henedy was away, she explained that he had been having “tick” like movements with his head several times over the week. She explained that Henedy was not aware of the movements because after they occurred he denied having done them. The Costa Rican doctor referred him to his neurologist.

One child came in complaining of chest pain and lack of breath while running. She was diagnosed with innocent heart murmur. This is a condition that usually occurs in children younger then 8 years and does no harm. There is only a pose of threat if there is a hole in the heart, a leak or narrow heart valve. Symptoms include sweats, cold, and loss of nerve function. This child was referred to a pediatric cardiologist for an EKG.

The community of Changuinola, Panama had the most memorable ninos. They posed for me with stories on their faces of where they had been. They were curious and eager to learn. They laughed at the language barrier because they barely spoke Spanish. I took the kids out of the clinic to explore their playing fields. Two ninos followed me with green unripe oranges in their hands. I asked them how they played. I wanted them to show me what their play time looked like. Either they didn’t understand my half Spanish/half hand motions or they didn’t know many games… so I set out to teach them a few. I showed them how to juggle oranges and how to laugh at yourself when you hit yourself in the face-- Doh. Once we had an audience of four more ninos, I showed them how to get in a circle and play catch. If they dropped it, they were out. They played several rounds and caught on fast.

Then they learned the game heads or tails, although I couldn’t use “heads” or “tails” with the language barrier so I used “uno” for heads and “dos” for tails. I tried to teach them that once they guessed wrong, they were out. They all wanted to stay in the game so much, they totally ignored that rule! I loved how they tried to impress me. Some of them would forget to yell out their guess before they threw the coin and would still act as though they won or loss. It was great to put that Costa Rican colon I would never use again to good use.

A 26 year old father brought his two year old son into the Panama clinic due to fever and cough. The father explained that he was a single parent to his son. The baby was full of personality and kept giving fists to everyone with a smile on his face. During physical examination, the child's heart beat began to increase and his breath rate shot up. It was apparent from lifting up his shirt and seeing his lung's struggle for every breath. Once his lips turned blue, he was rushed out of the examination room and given oxygen. It was a learning experience to see this baby go from play time to almost losing his life within seconds. He won the baby with the most personality award! Here he is shown giving fists to one of the medical students helping with the evaluation. This was taken minutes before he turned blue.

Por que vino hoy?

2008-08-08T23:02:00.000-07:00

(Why did you come today?)

Le pica?
(Do you itch?)

Es muy aguado o solo un poco flojo?

(Is it watery or just a little loose?)

These Spanish phrases became the topic for laughter but overused while working in the medical clinics of Costa Rica and Panama. Cases of diahrrea are as common in Central America as low back pain is in the states. Diahrrea is only the symptom of a worse diagnosis for parasites including worms (ascaris) and liver flukes (amoebas), irritable colon or mal nutrition. A parasite is an organism that lives off the host, the host being you or me. They are commonly transmitted to humans in diverse ways, such as insect bites, walking barefoot, human contact, animal contact, drinking water, eating under-cooked meats and fish, and numerous other ways that parallel life in Central America. The parasites live inside our bodies, feeding off either our own energy, our own cells or the food we eat, and even feeding off the health supplements we use. They are intelligent in their ability to survive and reproduce, which is of course, the purpose of any organism on this planet. You would rarely see such conditions in modern countries like ours, but here it is endemic. Although in recent medical studies, it has been estimated that 85% of the North American adult population has at least one form of parasite living in their bodies. Some authorities feel that this figure may be as high as 95%. "We have a tremendous parasite problem right here in the U.S. It is just not being addressed." - Dr. Peter Wina, Chief of the Patho-Biology in the Walter Reed Army Institute of Research in 1991. "In terms of numbers there are more parasitic infections acquired in this country than in Africa." - Dr. Frank Nova, Chief of the Laboratory for Parasitic Diseases of the National Institute of Health.

With a diet of rice and beans as a staple ingredient, high fat meats were usually the most desirable addition. This common diet led to around 3/4 of the patients complaining of diahrrea. Another observation that I have made is that the women do mostly all of the work, while the men lie around, smoke tobacco, enjoy fresh meat, beans/rice and then nap in the shade. The women have no such luxury. Their lunch consists of just rice (the men eat all the meat) and they are out laboring away under the scorching sun all day. The lack of protein/calcium intake is evident in their short stature, weathered skin, poor dentition and overall poor health as compared to the men. It is quite sad. The women tend to look older than their actual age, while the men look younger than they actually are. I made a point to give out as many multivitamins to the women as possible.

A Panamanian lady stated that she didn't know why all her kids and baby were sick. When I asked her what she fed them to be able to provide nutritional education, she said rice. Everyone in my medical team assumed she only ate rice and that was a problem. Since I didn't have a language barrier, I explored more and began listing common foods found in Central America. She agreed to eating and feeding her kids most of them. During the patient's assessment with the Panamanian doctor, the doctor told us that rice was becoming more expensive and only rich people could live off of rice alone. Therefore, it was confirmed that this lady did not just eat rice. It was important to find the cause of the diahrrea and not just treat it with the medication. In conclusion, this lady was lying about her reasons for coming. She was using the opportunity to get medication when she didn't need it so that she had it for when she did. Smart lady. I was told that this often happens and the medication is also sold within the community in times of need.

When I asked the lady for the baby's name, as we did as part of procedure for every patient, she said she didn't know. I asked her if it was her baby and she said it was. When I asked her again for the baby's name, she looked at her son and asked him to speak. I asked her oldest son and he said he did not know. He then took out a piece of paper and handed it to me. It was a paper that all babies are given with updated immunizations, as well as the baby's information. So I found out the baby's name, as well as the fact that the lady claiming to be the mother was not listed as the mother on the paper. No more questions asked, as long as the baby was being cared for... just wierd. That would not have been allowed in the states. Only the legal mother can attend to her baby at a hospital.

Diahrrea in adults usually means dehydration and lack of nutrients. They can be instructed to drink more water, given vitamins, and since it's usually a parasidic case they are given Albendazole and told to boil water first. Some other treatments include electrolytes, soup, no fruit (or juices) due to the high sugar content, chamomile tea, and juice from rice and cinnamon drink (horchata). If the severe diahrrea patient is under the age of 2, Albendazole can not be administered unless it is a proven diagnosis. The baby must have blood tests to determine whether it is parasites or not.

The beauty about treating infections in the 3rd world is that there is virtually no antibiotic resistance. Basic penicillin will kill just about anything. Amoxicillin, a derivative of penicillian, can treat acute and chronic UTI caused by strains of gram-positive and gram-negative organisms in the GI (dosage: 1 capsule for adults and liquid for children every 8 hours for at least 72 hours). With our high potency drugs the cure is so easy. We gave out two doses of Albendazole, which is all it takes to get rid of the worms. Albendazole acts by inhibiting the microtubles synthesis in parasites, which decreases their glucose uptake and causes them to die. As a result to these effects, the parasites die within a few days of treatment and will be expulsed from the GI tract. It also kills the future larvae and ovum produced by the parasite (dosage: adults 400 mg tablets/day for 3 days to 3 months, children 15 mg/kg).

For pain we gave Tylenol and Motrin, for abdominal discomfort we gave an assortment of Pepto-Bismol, TUMS, Nitazoxanide, and Ranitidine tablets. I encouraged them to drink plenty of water with the pills in order to help alleviate their dehydrated status.

It’s the future prevention of getting it again that seems to be the problem. Preventative medicine is largely nonexistent in this third-world nation. Little thought is put into the future. It is all about getting food in their stomach, and taking care of their immediate problems. I gave them instructions on how to care for their health because they just don’t think that way.

POPS

2008-08-08T19:58:00.000-07:00

There's a few things that runners think about before heading out on a run: running shoes, watch, hat, shades, ipod and a plan. The plan comes about pretty easily when you are in your own neighborhood. You may know certain paths' mileage and terrain like the back of your hand. In any case should you take a wrong turn, you just risk going over your desired mileage. Not a big deal!

Running while in a foreign country involves a lot more preparation than this. My first morning waking up at Casa Concordia in San Jose, Costa Rica was quite an introduction to the culture, community and what it takes to run in a foreign country. Having been traveling for 8 hours without any sleep the day before, I woke up longing for blood flow and my daily routine. I immediately jumped out of bed at the sound of the alarm, forgetting where I was and did my usual running preparation. When I realized, shoot- I'm not home, I added some minor details to my preparation: I hid my headphone cord in my tank and went to our Costa Rican team leader, Edwin to let him know that I was heading out (even though he had suggested I didn't the day before). He just smiled and suggested I run around the block and turn around because the streets were not like America's blocks.

My plan: run around the block, just like Edwin suggested. I mean, I can be stubborn and adventurous but I am aware that some people do know more than me. I headed out for a few minutes and looked out at the valley that was surrounded by volcanoes and cloudy skies. The sun was bright and I thought, what a great way to be introduced to this country. It's such an enjoyment to wake up in a new place and be surrounded by its natural beauty right away. It was just past 6 am and the streets were full of cars and people. I stayed on the main road and noticed how it slightly turned, but not enough to be unrecognizable on my return. I said aloud every sign I saw, hoping I would remember it on my way home.

There were wandering dogs and no sidewalks for me to run on. The streets were filled with dirt and cars were driving over piles of it. Nobody obeyed the stop signs and street lights. I stood out like a sore thumb with my bright tank and Nike shoes. I was aware of this and so as I passed Ticos, I put on the most aggressive face I had... it must have worked because nobody robbed my new green ipod shuffle!

Six minutes into the run, I turned around. Twelve minutes into the run, I knew I was in trouble. I had been on the same road yet had not seen one of the signs that I passed. Second guessing myself, I turned around and retraced my steps thinking I must have taken one side road without realizing it. I know I'm not perfect all the time, epecially at 6 am with no sleep! So as the retracing continued, I started coming up with Plan B. Plan B came sooner than I had hoped. I stopped at a factory where there were about 5 security guards outside. Plan B: ask directions to the POPS heladeria where I had ice cream last night. POPS heladeria was 5 minutes from Casa Concordia in a strip mall on a main road. I knew how to get to the Casa Concordia from POPS. Simple plan. Thank god I knew Spanish, although with my anxiety I have to admit that I made it quite obvious I was a gringa. For some reason, "heladeria" was not coming out right. "Hela, Helade" was all that came out. I was quite an amusing gringa for these security guards at 6 am. So one guy pointed towards the opposite direction I would have guessed and said 10 blocks that way and then left 10 blocks. Knowing that he was pointing towards the opposite direction, I asked him to confirm there was only one POPS in a strip mall. I also asked him to explain his definition of a block knowing that the streets were not laid out as blocks. He confirmed and I trusted my plan would work.

My run turned into a strategizing session with alternatives in case Plan B failed with an occasional thought about how I was going to train for the 1/2 marathon I had planned a day upon my return to the states. After 40 minutes of running in the opposite direction, I stopped a man with his young boys to confirm I was on the right path. He told me it was less than 10 blocks and showed me another way to get to POPS. Oh, latinos! Their directions included physical landmarks such as trees and buildings, not street names or address numbers. None of the buildings had addresses. I then stopped to confirm with a police officer who was standing a bit away from another police officer who had just begun confronting a drunk man laying on the side of a building. To my surprise the police officer was completely out of his mind and couldn't speak clearly. He was acting drunk and slurring his words. I thanked him and ran away.

Finally, I reached POPS and turned to Plan C. It was another POPS. I asked a girl outside to point me to the nearest POPS. She told me it was just down the same main road I was on and added that it was closed. The Tica must have thought I was a crazy gringa looking for ice cream for breakfast. I followed the main road until I came to a T. Plan D, which I was dreading like a day without sun, was soon in effect. I stopped a young boy walking the streets. He was still intoxicated from the Saturday night before and once he noticed I was a gringa, he stopped speaking in Spanish and started slurring, blah blah fuck blah fuck blah fucking. Really, all I understood was fucking and moved on, fast! By that time, I became upset because at that moment I was really concerned for my health and my safety. Unfortunately this trip was not suppose to be about me, but about bringing health and safety to the people of Costa Rica and Panama. I wanted to shift my energy towards getting out of this problem so I could focus on others.

Now I had been away for 46 minutes and knew that Edwin would not be worried yet knowing that I usually ran for an hour- a conversation we had the night before. While I was running I saw several groups of cyclists, all wearing matching jerseys and runners with bodies more ripped than most runners in the states. Knowing athletes and the mentality of serious ones, I knew I could trust one of them for help. At the T, I confronted a mid-aged male runner. I explained my situation and asked him if he knew where POPS in the strip mall was. He had no idea so we ran over to a group of people sitting on the steps outside a mall and asked them. They too had no idea! Oscar, the runner who I had stopped, led me running to the nearest store called Mas por Menos (More for less). During our run Oscar told me he had been a competitive athlete as a younger kid and now that he had a family, he raced local 10Ks. He said he only dreamed of running in the famous Boston Marathon. Visiting United States would be a challenge alone for him. Hearing that helped me shift the energy towards him. I totally forgot I was lost for a moment and really saw his life.

He bought an international phone card in the store and we set out looking for a pay phone that worked. 4 pay phones later, we both attempted several times unsuccesfully to make a call. Meanwhile, Oscar tried his house but no one answered. Just when we thought the phone card was worthless, he handed me the phone and told me to dial. Hmm, who do I call that would pick up and actually be able to help. I knew I only had one chance. Before I left, I gave all the numbers of where I would be staying and when to everyone in my family. I knew my sisters Teana and Afra never answer their phones, Sara maybe. Dad was somewhere in Bulgaria. My only hope... my mom. I dialed, she picked up. The phone card told me I had 5 minutes. I spoke clear and fast... "Mom, I went for a run in San Jose, Costa Rica. I got lost and I need your help. Please refer to the number for Casa Concordia and tell them the situation. Let them know I am on Calle San Pedro (San Pedro street) Mas por Menos. Mom, did you get that, repeat it to me." My mom then replied, Calle San Pedro and then the phone hung up on her. Oscar and I both attempted again several times to use the card again and failed. I just hoped that my lovely angels were working hard and that my mom heard everything and was taking action at that very moment. There wasn't any moment that I didn't think things would turn out perfectly, but I knew I was exhausting quite a few of my lovely angels. I was more worried because I knew I needed a few of those angels to spare to be able to leave some behind for the people I would meet there.

Oscar attempted his house one more time and to my luck, his wife answered. He explained the situation to his wife and handed me the phone. I gave her my mom's number and hung up. Minutes, I mean several minutes later she called us back on the pay phone. She explained that she got the number to Casa Concordia from my mom and called them for directions. The funniest part of the story lies in the close significance of the words, Mas por Menos (More for Less) and Mas o Menos (more or less). Because of the close relation my mom heard, more or less on Calle San Pedro- which doesn't clearly state where I was.

Oscar's wife explained she was on her way! Meanwhile, Oscar and I waited on the side of the road and we talked about races and he asked me to cure his knee issues (which of course is not possible in a few minutes on the side of the road). I gave him preventative tips, did some manual tests and analyzed his gait. I would have shined his shoes had I had the tools. The guy saved my life! Oscar's wife pulled up in an old, small car with their son in back and invited me to get into the passenger front seat. The first thing she told me was how far away we were from Casa Concordia. About 20 minutes later, we got to Casa Concordia. As she stopped, I told her to wait. I returned outside and handed her 10,000 colones ($20), the least I could give for saving my life. She denied it so I stuck it in her pocket through the open window. I gave Oscar a big latin hug and thanked them again for saving my life. I know my lovely angels spent quite a few days with that family.

Casa Concordia, Costa Rica: 1 day

Morning run: 2 hours
Gift for saving my life: 10,000 colones
# POPS heladerias in Costa Rica: priceless