Final Posting

My last week at PMGH was very nice. I spent a day in the outpatient clinic- antenatal in the AM and gynecology in the afternoon. Similar to the labor ward, the clinics are extremely busy providing care to well over 100 patients per day. For the remainder of the week I split my time between the labor ward and the operating theatre. I was able to see an obstetric fistula repair, do another term breech delivery, and several routine deliveries. Prior to leaving I was able to thank the faculty and registrars for their assistance during the stay and exchange contact information with several of them.

Arranging travel in PNG can be a bit difficult but Maureen and I really lucked out!! While there are several private tour groups in PNG they are outrageously expensive for a developing country and were out of the question for us. Due to safety concerns, just showing up to a new city, using public transport, and traveling like backpackers is not advised (especially for two women). Fortunately, I was able to make contact with an Australian, Jane, who is teaching midwifery at the University of Goroka through one of the midwives at PMGH (Florence who I mentioned earlier). Jane got us connected with Samuel, a local who arranges tours and is based in Goroka (much more reasonably priced). Jane also offered us a place to stay on the university campus… free of charge.

Maureen and I flew to Goroka (in the Highlands) last Friday with the hope of a cooler climate, beautiful scenery, and a climb up Mt Wilhelm (the highest peak in Oceania- 4,509 meters). We were not disappointed… just required a sense of adventure. Samuel met us at the airport and accompanied us on the PMVs (public motorized vehicle) to Jane’s house on the university campus. Jane lives in a beautiful 4 bedroom home by herself so often hosts travelers or expats new to Goroka (while they make arrangements). Aaron, an Australian documentary film maker is currently living with her.
We dropped our luggage there, finalized plans for our trip up Mt Wilhelm, and made arrangements to see the Asaro Mud Men that afternoon. PNG is home to hundreds of tribes/clans many which still live/celebrate traditional village life. The Asaro Mud Men are one such group. Asaro village is northwest of Goroka and is famous for its mud men- warriors who covered themselves with mud and wore mud masks before heading off on raids. The village people now recreate this for tourists… a bit of a tourist trap but still interesting to see and the pictures are pretty priceless (Maureen and I even modeled the mud masks). We also had the village people teach us how to chew betel nut- a seed which is chewed with mustard and lime powder to obtain a stimulant effect. We weren’t much good at it and spit it out before any real effect. It was a good laugh though.
Friday evening Jane, Aaron, Maureen, and I went to dinner at 1 of the 4 restaurants in Goroka… we were joined by what must be most of the Goroka expat community. There were about 20 of us in total… people from all over the world who have been in PNG for varying lengths of time working for many different organizations. Dinner conversation was spirited to say the least. Saturday morning we met Samuel downtown to begin our trip up Mt Wilhelm. We traveled first by bus (PMV) for several hours along the Highlands Highway (another pot hole ridden road) through beautiful mountains to Kundiawa. In Kundiawa, we loaded into the back of a Toyota 4WD pick-up truck with locals (men, women, children, and 1 baby) and headed to the guest house in Kegsugl. The poor condition of the road was quite unbelievable but luckily was matched by breath taking scenery. Maureen and I bounced around together for several hours and ended at the East Kegsugl Guesthouse with sore bottoms.

The East Kegsugl Guesthouse is owned by Josephine and Arnold and is just down the road from the trail head. We slept there Saturday night after enjoying a home cooked meal (Josephine prepared over a fire) of veggies, rice, sweet potato, and fresh strawberries. Sunday morning with our packs on our backs we met our guides (Michael and John- two locals) and headed for base camp. Along the way we admired incredible gardens (the climate in the highlands provides plenty of rain and spring like conditions year round), purchased the veggies we would eat while hiking, and headed into what looked like a jungle with occasional pine trees. We hiked for about 5-6 hours (though the jungle and grasslands, passing waterfalls and interesting plant life) reaching base camp (called the A-frame) mid afternoon. We dried out our socks/shoes (Maureen and I only had running shoes…) and enjoyed the weather/scenery. The base camp is just next to one of two lakes found part way up Mt Wilhelm.
Sunday evening we ate dinner by candle light (veggies, rice, and potatoes) and went to bed early as the plan is to wake up at 1 AM, begin hiking at 2 AM, in order to summit early morning and be off the mountain by midday. After about 3-4 hours of sleep we were up, dressed, and ready to go. From 2 AM till sunrise we hiked with flashlights… a bit eerie as I had the feeling we were going straight up and was apprehensive about the trek back down. However, after a bit of reassurance and the assistance of our amazing guides (could not have done it without them) Maureen and I made it to the top!! We saw the most amazing star filled sky, the moon rise, the sun rise, the southern coast line of PNG, cities and rivers in the distance, several mountain ranges, rainbows through the mountain mist, the site of a WWII plane crash, and several mountain lakes. The trip was 6 hours of hiking up and about 5 back down to base camp. We both agree it was worth every bit of effort, wet feet, cold hands, bruised shins, and sore muscles. We rested at base camp for an hour or so, packed up our stuff, ate some lunch, and then walked the rest of the way down to the Guest House. After 15 hours of hiking we had dinner with Josephine, a cold shower, and went to sleep.
Tuesday morning, around 6 AM, we loaded into the back of a truck for the trip from Kegsugl to Kundiawa to Goroka (and the hope of a hot shower). As we traveled down out of the mountains the truck, which started with Maureen, Samuel, and I, slowly filled up. We stopped frequently picking up people and produce as they were headed to Kundiawa (they were headed for the market). Eventually, Maureen and I, deemed as taking up too much space in the truck bed, were told to sit in the cab of the truck. Although this afforded much less fresh air my sore body welcomed the padded seat. Once in Kundiawa, we boarded a bus to Goroka and arrived at Jane’s house by noon. After hot showers, laundry, and lunch we enjoyed an afternoon on reading on Jane’s deck overlooking the mountains we had just come from.
Tuesday evening we treated Jane to dinner at a second of the four restaurants in Goroka to thank her for her hospitality. As I said before Jane is currently teaching midwifery at the University of Goroka. She is a fascinating woman who has spent her entire life traveling. She has done 9 missions with Doctors Without Borders (MSF)- taking her to several parts of Africa, China, and the Middle East. I think both Maureen and I were in awe of her experiences. On Wednesday morning, Jane took us to the airport for our return flight to Port Moresby (it took us a bit to get checked in for a flight as the ticketing counter was basically in a shed and was not clearly marked).
As I type now, we are on Loloata Island just off the southern coast on Port Moresby. The idea being Highlands to Islands as Maureen has dubbed it. Loloata Island is located in Bootless Bay and is home to a small resort- currently we are 2 of 6 total guests. We will spend two nights here admiring our ocean view. The plan is to relax, read, reflect, and catch some rays before the return to reality. Maureen plans to do some scuba diving as well. Both of our flights leave early Friday AM.
Overall, my trip to PNG was not what I expected (I suppose this is the trend when traveling to a developing country). I greatly enjoyed my time in the hospital, the people I met there, and am thankful for the experience. Hope you have enjoyed reading/following along. All for now.

4/1/13: I have a roommate!

The remainder of last week went quickly. I was in the operating room
on Thursday and then Maureen arrived on Friday. The case list for
Thursday included a cesarean section with tubal ligation, four tubal
ligations, a vaginal hysterectomy for prolapse, and a few dilation and
curettages. Friday was a public holiday (Good Friday) and Maureen was
scheduled to arrive midday. Skanda picked me up after completing AM
ward rounds and we were off to the airport.

We met Maureen in the international terminal. I am very glad she is
here to join me and I anticipate we will have some great memories at
the end of this trip. For those who don’t know, Maureen is an OB/GYN
who was in my residency program at Ohio State. She is two years ahead
of me so is now an attending physician. She and her husband, Dave,
live in Columbus, as he is completing a chief year in
medicine/pediatrics. Maureen and Dave have done a fair amount of
traveling together (both on medicine related trips and for pleasure).
They will be spending next year in Tanzania working for the medical
division of the Peace Corps. Maureen had quite the experience
traveling- she was kicked off a flight, re routed on two different
airlines, and arrived with no luggage…

Regardless, we went back to the hostel from the airport so she could
shower and have a rest (luckily we wear the same size cloths). As
Maureen adjusted to the time change I relaxed, did some reading, and
writing. We contacted Dave through Matt to work on the luggage
situation.

On Saturday morning, we went with Delly and her family to the Ela
Beach Craft Market. It is a market put on the last Saturday of every
month in Town. There are daily markets all over Port Moresby but most
on not safe for foreigners to wander around. The Ela Beach Craft
Market is hosted on a fenced off school yard. We wander around and
purchased a few things. Mostly it was just fun to look at all of the
paintings, carvings, woven bags, and jewelry. After we had our fill
we walked down Ela Beach to the nicest hotel in Port Moresby for some
breakfast.

Port Moresby is on the southern coast of PNG and has really lovely
scenery- green hills/mountains abutting blue/green ocean. That being
said it is not safe to walk the beaches alone or in the evening/night.
There are always a fair number of locals hanging around selling
things, swimming in the ocean, and playing volleyball. Given we were
a large group and it was midday we decided to wander around. Ela
Beach Hotel is just across the street from the beach behind a large
security fence and guards  We went into the restaurant and air
conditioning for a quick bite. Maureen and I shared a plate of fresh
fruit and cream… the mangos were so delicious. After breakfast we
said goodbye to Delly and her family. Skanda, Maureen, and I did a
quick tour of the city by car and then a walking tour of the hospital.

In the afternoon we went to Skanda’s place for WiFi to make some
travel bookings for next week as Maureen and I plan to go to the
Highlands of PNG and Loloata Island. Saturday night the three of us
went to an Asian Fusion Restaurant which was quite good. Like I have
mentioned earlier the restaurant/grocery store scene has a lot to
offer. It primarily caters to the large number of expats living in
PNG as the prices tend to be relatively high. Expats have come to PNG
for mainly 1 of two reasons- to get rich off of the natural resources
(oil and minerals primarily) or to provide aid to a developing
country. In many ways these two are related… if industrialized
nations are going to come in to exploit local resources they often
feel the need to give some level of support to the people. It is an
interesting system… for better or worse.

On Easter Sunday we woke up early to go to the fruit/veg market put on
by a local university (Pacific Adventist University). The market is
run by the students and is very nice. We also sampled some local
foods which are sold outside- Maureen had a sausage, I had a large
piece of chocolate cake, we shared a chicken roti, and we purchased
iger to have for dinner later on. Iger is a local dish which usually
includes potatoes, cooking bananas (think plantains), greens, chicken,
and spices all wrapped in large green leaves and cooked in a pit of
hot stones.

After the market we went by the airport to see if Maureen’s bag had
arrived. The attendant at Air Niugini was very helpful and said it
should be arriving on the afternoon flight from Brisbane- we were just
to come back around 5 PM. We were both a bit skeptical given the
overall efficiency of this place and the jumbled up manner in which
Maureen got to PNG (there was also no tracking number involved… just
Maureen’s name). However, sure enough, when we returned at 5 PM
Maureen’s luggage had arrived!!! Maureen and I decided it was an
Easter miracle. We played some cards in the evening and for our
Easter Dinner heated up the iger on the stove and made a monster fruit
salad with our purchases from the AM (mangos, papaya, oranges, banana,
grapes, and sugar fruit).

Today, Monday, is also considered a holiday but we decided to come to
the hospital for awhile. I tried to photo document this place as
there are fewer patients around given the holiday (I will post them on
FaceBook when I return to the US and have good internet access). I
have not entirely decided what I will do this week- likely spend a day
or two in the outpatient setting, round on the gynecology service, or
maybe return to the OR/labor ward.

As of now, Maureen and I, are flying out of Port Moresby on Friday to
go to Goroka in the Highlands. We hope to hike near Mt Wilhem and
maybe see some birds of paradise. We return to Moresby on the
following Wednesday and will then go to Loloata Island for two nights.
On the follow Friday (April 12th) we leave on separate flights back
to Australia. I will try and write more about this as we are going if
I can get internet to post again.

Update on 3/27/13

Update on 3/27/13:
Overall I had a pretty good birthday weekend. On Saturday, Delly (one
of the registrars), along with her husband and daughter- Evelyn, came
to pick me up. Our plan had been to go to the craft market but turns
out it isn’t till next weekend. Instead we went to the “mall” which
consists of a few shops and a grocery store primarily catering to
expats living in Port Moresby. The grocery store, Food World, was
actually quite extensive (compared to my time in other countries you
really can buy most anything here… just have to do a bit of looking).
I was able to find an ATM, drink a coffee, and get a SIM card with the
hope of WIFI. Evelyn was very entertaining and I am quite envious of
her energy.

Delly is considered a senior registrar here which is about equivalent
to my level of training. We spent my entire first week on labor ward
together. She is a very skilled physician and delightful person. The
training system in PNG is a bit different than the States- it actually
takes longer!! After secondary school (high school), trainees enter
directly into medical school for 6 years, then they become a resident
for 2 years (this involves rotating on all services, similar to a
general intern year in the US), then on to service years (which from
what I can tell involves 1-2 years working in an undesirable location
as a generalist), and then onto specialty training where one is called
a registrar- OB/GYN here is 6 years. After completion you are called
a consultant (equivalent to an attending physician in the US). I
still haven’t entirely ironed out whether everybody has to do service
years. Most of the registrars are married and the majority of them
start their families during training. Delly said that on average
physicians are in their early to mid thirties when they have completed
their training.

On Saturday night, Skanda and I were invited to dinner at Florence’s
home. Florence is a midwife working for the WHO teaching midwifery at
a local university. She is from Australia. Along with her husband
Filipe (who is French) and son Archer, Florence has lived in several
different places doing humanitarian work. The evening starting with a
riveting game of Go Fish (Archer is 5) and ended with a conversation
about Florence’s work in Darfur. I really enjoy talking with her and
feel as though we are kindred spirits. She and Filipe were actually
in Timor-Leste at the same time as me in 2010… she too got dengue.

Sunday morning (my 29th birthday) Florence and Archer came to pick me
up for a swim at the Aviat Club. Archer surprised me with balloons, a
birthday horn, and a present… I pretty sure it’s because I’m such a
good Go Fish player. At the Aviat, I was able to do some lap swimming
(which felt great as I haven’t exactly been able to go out for a run
here) and play with Archer. We then went back to Florence’s place for
lunch and so I could use the internet (I was able to get Wifi working
at my hostel for a short period of time but it is very spotty… and
slow). For those that were able to get through- I appreciate the
birthday calls, text messages, and emails from home!! Sunday evening
Skanda, Professor Mola, 2 of the registrars, and I went out for a
birthday dinner (and Mom don’t worry I was even able to have birthday
cake). I hope being 29 is as good as being 28… and that it lasts
awhile… 30 doesn’t seem possible.

I decided to spend my second week in the operating theatre… which to
this point I am happy to say has been an excellent idea. There is one
registrar assigned to the operating theatre (which is Frank currently)
and a different attending physician each day. There is supposed to be
a resident as well… but they haven’t seemed to show up… lucky me .
The operating theatre handles all of the obstetric and gynecology
cases. There are 2 operating rooms, each with a dedicated anesthesia
and nursing staff (however… they don’t show up till 10 AM sometimes).
Anyways, overall the facilities are basic but serve their purpose. I
have never seen supplies conserved to this extreme- who knew 1 piece
of suture could be used to do an entire tubal ligation from start to
finish.

Each day’s case list is quite long… Frank and I start at the top and
just power through. The consultants are present- sometimes scrubbing
in to help and sometimes not. The most common procedure done is tubal
ligation… I think we are single handedly sterilizing PNG. No, in all
seriousness, there is a huge push for family planning here given the
poverty, lack of education, and overcrowding. Most days there are
6-10 tubal ligations completed under local anesthesia with a bit of
sedation. The remainder of the case list so far this week has
consisted of several dilation and curettage, several exams under
anesthesia (primary for advanced stage cervical cancer), a few
cesarean sections, several exploratory laps for ovarian cysts (think
the size of a watermelon), and a few hysterectomies. (and it is only
Wednesday!) The registrars have great autonomy here and are very
competent. The general principals in the OR are similar to home… with
a few modifications (the most drastic- there are no emergent, or even
urgent, cesarean sections- but with no fetal monitoring I’m not sure
what I was expecting). Today a cesarean section which was being done
for “fetal distress” was postponed till after a hysterectomy (I was a
bit anxious to say the least… but in the end the baby was ok…
luckily).

Regardless, I am looking forward to the rest of my week. Oh and
Maureen arrives not tomorrow but the next day (Friday March 29th)… I
had the hostel attendants make up her bed and bring in extra towels 
Yah to not living alone anymore.

Week 1- 3/23/13

Sorry for the delay in posting… the internet situation around here is a bit ridiculous… no internet at my hostel (not surprised) and no internet at the hospital (surprised). Can you imagine no internet at OSUMC?? Anyways, I have arrived safely in Port Moresby, PNG and have completed my first week at the hospital… which has been interesting to say the least. I will try and hit on the high points.


I left LAX Tuesday, March 12th after a very informative 4 day conference on gynecologic cancer. I flew overnight on Virgin Australia to Sydney and then on to Cairns. I’m happy to say my 15hr trip from LAX to SYD involved having an entire row of seats on which I stretched out and slept soundly for 10 hours (may have been a bit behind). When I arrived in Cairns I was greeted by a dear friend, Dan Foster, who I worked with in Dili, Timor-Leste in 2010. Dan is currently a resident in Australia and lives with his girlfriend Lani in Cairns. I stayed with them for an evening and had some time to catch up/reminisce about our time in Timor-Leste. Dan took me to the airport Friday, March 15th for my flight to Port Moresby. Much like my flight to Timor 3 years ago, after just 1.5 hours in the air I went from the western world to a developing nation.
It took a bit to obtain a visa and get through customs at Port Moresby Airport… and then there was no one there (I was expecting Professor Glen Mola to pick me up). Having read heaps of things about how public transportation is not the safest for expats in PNG I surely wasn’t about the hail a cab or take a bus. I sauntered over to the Digicel stand and while purchasing a SIM card for my cell phone (not that I had any numbers to call once my phone was working) was approached by a man in a hotel uniform. Clearly he could tell I was a bit out of place. I told him I was just waiting from Prof Mola to pick me up. Now Port Moresby is a city of about 300,000 people so I did not expect this man to know who I was speaking of. However, he quickly explained the Prof Mola had done surgery on his mother, how he was a great doctor, and he would just give him a call. Shortly after Prof Mola and Skanda (an Australian OB/GYN who is working at Port Moresby General Hospital, PMGH, for about 6 months) arrived to pick me up. Sigh of relief.

From the airport we drove down pot hole ridden streets to my accommodations. I am staying in a hostel across the street from the hospital called the CWA. I have a private room with two single beds (one for Maureen when she arrives), a private bathroom, and shared kitchen facilities. When I arrived there were two ladies from Australia in one room, a Timorese doctor in another, a PNG doctor in another, and a biologist from Finland in another. The room is clean and very comfortable aside from the lack of AC. Just a bit hot/humid for this Midwest girl… but I am able to sleep at night with the ceiling fan on.

I dropped my bags and proceeded to PMGH for a tour of the OB/GYN department with Skanda. The department is set to the back of the hospital facilities. Overall, I would say the facilities are adequate and serve their purpose… nothing fancy. There are 4 wards- Ward 9 is the gynecology ward, Ward 10 is the antenatal ward, Ward 11 is the postnatal ward, and of course the labor ward. The operating theater and special care nursery are attached to labor ward. Each ward is open (Florence Nightingale style- no private rooms) with curtains between beds.

The remainder of my first weekend involved dinner with a group of expats (primarily nurse midwives from Malawi, Australia, and several European countries all working for the WHO teaching local midwives), some grocery shopping, visiting a local fruit/veg market, a swim at the Aviat Club (think country club pool with no golf course- Aafke, an OB/GYN from Finland who has worked at PMGH for 6 years and her husband took me), and trying to adjust to the time change.

I decided to spend my first week on labor ward (with plans to do GYN/OR and outpatient work the next two weeks). Every day begins with morning report (generally involves some sort of didactics for the residents, registrars, and medical students) and then ward round. Labor ward at PMGH has 24 beds, a small waiting room, and a triage room with 2 beds (although I have not really seen this triage room used- mostly mothers just labor on a bench until a bed becomes available). PMGH does about 12,500 deliveries a year… that breaks down to about 35 deliveries a day. It is an extremely busy unit staffed by residents/registrars and midwives with one attending (called a consultant here) overseeing.

Women labor without epidurals and without fetal monitoring. Some have IV access some don’t. There is one external fetal monitoring machine for the entire unit which is wheeled from bed to bed when there is concern for fetal distress (I won’t get into the nitty gritty details of L&D as this blog is for a diverse audience… but for those interested we can talk more later). Week one involved several cases of pre eclampsia, 2 cases of eclampsia, 3 vacuum deliveries, 3 twin deliveries (2 of which were undiagnosed and came from the antenatal unit- ultrasounds are not done routinely), 2 breech deliveries, only 1 cesarean section, and a few post partum hemorrhages. Antenatal care is spotty at best and doesn’t include things like accurate dating, determination of blood type, or determination of GBS status… just to name a few things. Doctors, nurses, and midwives all do each others’ jobs- everyone delivers babies, everyone starts IVs/draws blood, and everyone administers medications. To give some idea here are a couple stats for the month of December- there were 1066 deliveries, 11 of which were breech, 70 of which were vacuum assisted (really no forceps), and only 42 cesarean sections (rate of 3.8%). So yah… all in all it is an interesting place.
The staff at the hospital are lovely people and very helpful. Overall, everyone I have met is very kind and anxious to go out of their way to make me feel welcome. In the evenings I have been reading, writing, and wishing I had internet. I do have a cell phone (# 70596397) so feel free to call or text… it is a bit lonely- given concern for petty crime it sort of feels like I am on house arrest. I go from my hostel to the hospital (generally accompanied by someone) and back again. I look forward to Maureen’s company in less than 1 week.
I spent my Friday night having dinner with Aafke and her husband at their home. As I mentioned before Aafke is an OB/GYN who has been living in PNG and working at PMGH for about 6 years. Her husband (I can’t spell his name) is a professor of political science and works at the university. They are originally from Finland but have worked all over the world… primarily spending 20 some years in Africa. Aafke completed her training in England but has not worked in the western world at any point in her career. Needless to say they have great stories. Her husband is the first person I have met since leaving that knows exactly where Iowa and Ohio are (due to holding the first primary and being a swing state, respectively). It is always interesting to hear what others think of the States... Regardless we had a very nice meal and I appreciate their company.
As for the rest of my weekend… I plan to go to the craft market with Delly (one of the residents I worked with in labor ward) and hopefully buy a SIM card to set up WIFI at my hostel. A group of us may go to the fruit/veg market on Sunday morning to buy groceries for the week. Oh and I will turn 29 tomorrow… bummer. All for now.

Finishing Up…

5/3/2010-

I have only two days left at Hvidovre University Hospital here in Copenhagen. The four weeks went by fast… it was a great review of some basic OB/GYN (which will be helpful starting residency in the near future), the staff/students have been very helpful and friendly, and most of all the work hours have been more than reasonable. I am trying to savor every moment of free time here (there are plenty of them) with the knowledge that my life is about to change drastically to 80 hour work weeks and only 2 weeks of vacation all year. Scary! I have read a couple of books, been running and biking, and spending time with Rebecca around Copenhagen.

Two weekends ago Rebecca and I did some shopping, wandered through the palace/royal church, enjoyed ice cream, saw Alice In Wonderland in 3D (AWESOME), and went to a ballet titled Shakespeare in Motion. Rebecca flew straight from Africa (where she was completing another medical elective) to Copenhagen… needless to say her bags did not follow her here. Then the volcano erupted… so about 2 weeks later Rebecca finally got her luggage. However… there is a silver lining. She had travel insurance which will cover $500 worth of expenses per 24 hours you are without your luggage up to $1500. This translated into shopping spree to both Rebecca and I. I helped her pick out some cute clothes from the shops downtown!! (I refrained however seeing as the exchange rate is no good… I did not lose my luggage… and everything is expensive anyway) The movie and ballet were both entertaining. Rebecca and I had to do a bit of research after the ballet was over as we were totally lost as to which Shakespearian story involves a dancing bear… I was made very aware of my lack of cultural exposure (it is a stage direction in A Winter’s Tale). Oh well… we still had a wonderful time.

This past weekend we had big plans of a picnic/afternoon of reading in the park and a day at Tivoli (amusement park in Copenhagen). But… plans change. It rained almost all weekend. Instead of a picnic Rebecca and I went to our local bakery and each got 3 pastries for 25 kroner (about $5). What a deal. So we ate pastries for lunch and watched My Girl on TV while it poured down rain. Friday night we met up with some friends for drinks downtown… a very nice evening. On our Tivoli day we ended up going to a park where all of the political parties of Denmark gathered for a 1st of May celebration… basically looked like any city fair (tents, music, food/drink). Since we didn’t understand any of the political speeches (they were in Danish) and it was raining we didn’t stay too long…. well we stayed long enough to partake in lunch. Crepes with ice cream anyone??? Sunday… it was finally SUNNY! Rebecca and I went down to the waterfront near our apartments and spent the day reading in the grass. The wind was a bit chilly but the sun warmed us. There were a few crazy Danes swimming… it is not warm enough to go swimming here.

For my last week in Copenhagen I have big plans. I have finished up the requirements to get credit for this elective… so I am technically done with medical school!! How exciting is that? Thought the day would never come. So now for celebration... on Wednesday a group of us are going to a soccer game… if I understand correctly it is the club championship for Demark. One of the teams is from Copenhagen and the other from just outside the city. It should be a fun evening. On Thursday I have to return my bike (sad) and then Rebecca and I are going to attempt an afternoon at Tivoli. Fingers crossed for good weather. Friday Matt is coming to Copenhagen!!! He is in Europe for work right now and is coming to visit me for my last weekend here. Andres, Anne, Matt, and I will travel to Aarhus on Friday to see Matt’s former foreign exchange student (and Andres’ sister) Mette defend her PhD thesis. It will be a great chance for Matt to see Mette again and for me to meet her/the rest of the Larsen family. We plan on returning to Copenhagen on Friday evening. Matt and I will be going to a play in Copenhagen on Saturday night and then meeting with one of the actors for a beer afterwards (Matt’s Aunt Laura is an actress and while studying in Denmark in the past met an actor here… we will be seeing his play and meeting up with him afterwards). Sunday… hopefully Matt and I can have a quiet day together before the craziness of graduation/moving/residency starts. Monday morning Matt will head to Italy for work and I will head home. Graduation is Friday.

I have had a great time here in Copenhagen but am ready to be home with family and friends for a bit before the next step. Given the restrictiveness of residency I will likely not be traveling/blogging for a bit… so for those how have been reading thanks and I hope you have enjoyed it. Until the next adventure.

Two weeks almost over already...

4/23/2010-

So… I have now been in Copenhagen for almost 2 weeks (1/2 of my time) and I haven’t blogged since I arrived… where has the time gone? Okay, here is an abbreviated update. I started at Hvidorve Hospital in the Ob/Gyn department and so far my time there has been great. I am on a rotation with about 12 Danish students and one other foreigner, Rebecca, from New Zealand (my new best friend). The hospital is a relatively large teaching facility associated with the University of Copenhagen. The level of care available is very similar to the US- which has been nice after spending time in an area with limited resources. It feels good to be able to offer patients optimal services. So far I have been rotating through the gynecology department (I will do obstetrics at the end of my time here). I have spent days on the inpatient ward, the operating theatre, the same day procedure room, and the outpatient clinic. Our mornings start at 8 AM with general rounds and then we go with our assigned physician for the day. Things tend to wrap up around 3 PM…. that’s right… the day last from 8 AM till 3 PM (Danes have a great appreciation for quality of life which means work hours are extremely reasonable). I have been biking to and from the hospital with Rebecca (who is basically my neighbor… so convenient) and it has been great. The trip is about 12 km one way and is a nice start and finish to the day- especially when you have time (minus getting stuck in the rain the other day). I have also been running by the water almost daily… the trails through the city are extremely well kept.

With spending comparatively few hours at the hospital, Rebecca and I have had ample time to explore the city. Copenhagen is beautiful, clean, organized, and just all around pleasant. Only drawback… it has been a bit chilly and windy here (a result of being so close to the ocean). So what have we done in the city to far….

Last Friday was the Queen of Denmark’s 70th Birthday. It was a great celebration. Rebecca and I were wondering downtown and before we knew it people were handing out Danish flags and lining up for a parade. Shortly after a small band, lots of uniformed Danes riding horses, and the Queen waving in a carriage passed by. We followed the parade and group of people to the City Square where she went to the balcony of City Hall to wave at her adoring people. After her appearance there was cake… that’s right… in the middle of City Square there were several large tables set up covered with free birthday cake for the people who had gathered. It was delicious! Rebecca and I spent the remainder of the day strolling around the city.

On Saturday… Rebecca and I took a canal tour which was a great way to get the lay of the land. We found a pizza buffet near the Central Station and enjoyed pizza and a beer for dinner. Rebecca is also a final year medical student interested in Ob/Gyn. She recently spent 6 weeks in Africa on placement at an HIV/AIDS clinic. We have many similarities and I am so thankful she is here. It is always more fun exploring with a friend. After dinner we met with Tobias, my mentor, and some of his friends for a few beers. The evening was very nice… except my phone was stolen out of my coat pocket at one of the pubs… bummer. So I now have a new number (Andres and Anne had an extra phone I will be using… just had to get another SIM card) +45 71 14 57 18.

Sunday, Andres and Anne picked me up at 10:00 AM and we drove north of Copenhagen to a castle (Kronborg), the oldest amusement park in Denmark (Andres and I took a trip on the wooden rollercoaster), and to the royal forest/hunting ground. It was a truly great day and I so appreciate their hospitality. Upon returning to Copenhagen we went over to Andres’ brother Soren’s house for dinner. Soren and his wife Anya have two beautiful children, Camilla and Mickel. Dinner was a delicious traditional Danish meal complete with crepes and ice cream for dessert. YUM!! Andres’ sister, Mette, was an exchange student of Matt’s family when he was in high school. Their mother, Bodil, was an exchange student of Matt’s mom when she was in high school. Mette is a physician in Denmark and will be defending her PhD thesis on my last Friday here. I hope to travel with Andres and Anne to see the defense and finally meet Mette (and the rest of the Larsen family).

Week two at the hospital was as enjoyable as the first. Rebecca and I went in on Wednesday when all of the other students had classes in Danish. Being the only students there… the head of the department was so pleased to see us at morning rounds he did part of them in English in our honor (it was so nice to be able to understand). I also got to be first assist in 3 urogyn. surgeries which was great. That evening we went to a movie at the Cinema with Tobias and his friend Frederick. In Denmark all films are shown in the original language with subtitles… so Rebecca and I could understand!!! Yeah. The theatre is in the newer part of Copenhagen… basically a large shopping center and apartments very similar to what you would see in the US.

This weekend Rebecca and I have more big plans of exploring the city… maybe some shopping, touring a few museums, wandering around the palace/royal cathedral, and possibly seeing a ballet. We have a list of things we would like to do before our time in Copenhagen is over…. So we just keep moving.

Side note- an obligatory part of exploring any new city/country is partaking in the local cuisine. In case there was any concern… Rebecca and I are doing a wonderful job of this… pastries, lattes and cake, ice cream, sea food, fresh salads w/ amazing bread. It is all sooo delicious. I am trying to exercise some self control. That is all for now. Hope all is well on the other side of the pond.

Welcome to Copenhagen...

4/13/10-

Just a short note to let you know I have arrived safely in Copenhagen and am settling in well. I landed on Sunday around noon and was met at the airport by my mentor, Tobias. He is a final year medical student at the University of Copenhagen. We will both be spending the next month at Hvidovre Hospital in the OB/GYN department. Tobias spent some time at the University of Iowa last summer/fall working in cardiology. He was kind enough to meet me at the airport and help me navigate public transportation to the apartment I will be renting for the next month. I am staying in a two bedroom unit in Amagar, which is just south of the city. The accommodations are very nice… complete with kitchen, bathroom, internet, and cable. What more could a girl want? I will be here alone till the beginning of May when an Italian engineering student will move into the other bedroom.

After dropping my bags off Tobias and I had lunch and saw a bit of the city. I returned to my apartment, went for a run, and tried to stay awake as long as possible… attempting to adjust to the new time zone. I made it till 9 PM… and awoke at 8 AM Monday morning feeling refreshed. I explored my neighborhood, found the local Aldi grocery store, and then jumped on the metro to the city. I activated my cell phone… so feel free to call +45 50 17 58 66. Tobias and I again met for lunch. And… I got a bicycle!!! Everyone gets around Copenhagen on bicycles… so now I fit in. Tobias looked a bit concerned about my cycling abilities (I don’t have a bike in IC so it has been several years since I have ridden). I said “No worries Tobias…” and rode to the grocery store and then home. This morning (Tuesday) I went for a run along the water and will be heading into the city shortly. I am meeting up with Andres and Anne (friends of Matt and I’s who live in Denmark- we stayed with them in Jamaica three years ago over a spring break) this evening for dinner. My placement at the hospital begins on Wednesday which should be interesting. All I know so far is we work from 8 AM-3 PM Monday-Friday… pretty nice!

3/8/2010

Last entry for this trip…

The week of 2/22-2/26 was filled with mobile clinics. Eva and I were able to go to a number of them together which was great. We loaded up in the 4 wheel drive after rounds and got out of Dili for the day. The majority of complaints at mobile clinic are things like headache, backache from working in the fields, cough/runny nose, diarrhea/vomiting, a few fevers, and skin infections. As far as treatment that can be offered to the patients at mobile clinic, we tend to give out Tylenol, ibuprofen, multivitamins, vitamin C, occasionally antibiotics, and albendazole (for all of the little kids with intestinal worms). We are also able to do rapid malaria tests and take sputum sample to evaluate for tuberculosis. While only the antibiotics and the albendazole are actual therapeutic treatments by western standards the majority of these patients are satisfied by the placebo effect provided by the vitamins and the like. It is important that these patients not leave the consult empty handed and feeling as though the visit wasn’t worth their time (this could deter them from seeking care on other occasions when they may be affected by more serious illness). Patients are always encouraged to return if they do not feel better and given that all services are free the system seems to function rather well. Recently a midwife was added to the mobile clinic staff which is great as the majority of women in more remote locations receive no pre or post natal care.

The week passed by quickly and on Friday the 26th we all got together to celebrate Dan’s 31st birthday (or the 10th anniversary of his 21st as we referred to it, side note- While turning 21 is a big deal for Americans due to the legal drinking age this is not the same for Australians who can drink at 18. However, turning 21 is significant to them for a different reason. In Australia, when you turn 21, you get the keys to your parents’ house… symbolizing you are old enough to come and go as you please….?. This tradition is still a bit puzzling to me as I wonder why one is living at home at 21- Dan suggested it is just an old tradition and admitted it doesn’t make a whole lot of sense. (Crazy Aussies.) Anyways, we went out for Indian food and surprised Dan with a chocolate cake with candles which read, “Parabeins Maun Dan” (Happy Birthday Brother Dan in Tetun). Dan was still not feeling well (turns out he got dengue also) but put on a good face and even joined us for a couple of beers after dinner. We said goodbye to Liam Friday night before heading home as he left Timor Saturday morning. Eva and I are so thankful for all of the people we have met here in Timor and have found the goodbyes a bit sadder than we anticipated.

The remainder of our last weekend in Timor was rather uneventful. We rounded in the mornings, enjoyed a few cups of café Timor (organic coffee grown in the mountains of Timor is one of the country’s most promising sources of income- it is soooo good), went to Hotel Timor for lunch and dessert buffet, hunted for internet, and had an afternoon by the pool. The weather continues to be extremely warm and humid. While it is currently wet season… the rain has not been overly impressive as it has been a “dry wet season.” The increase in dengue on the island has been attributed in part to this- a dry wet season means more standing water and thus more mosquito breeding ground (when there is more rain the rate of water turnover in the rivers/fields/puddles is greater).

Eva and I worked at the clinic on Monday and Tuesday of last week. We took Wednesday and Thursday to see a bit of Dili, wrap of loose ends, and pack before flying to Darwin on Friday. Unfortunately our last two days of clinic were disheartening. On Monday, we received news that a 15 year old boy who had been at BPC for well over a week passed away after being referred to Dili National on Sunday. It was again another example of referring the patient on too late in the disease course leading to a bad outcome. The boy had come for consult, was found to have significant lung disease (likely tuberculosis with a superimposed infection), received less than adequate care due to resource/staffing issues at BPC (we couldn’t provide oxygen by face mask for this patient), he continued to decline, the suggestion of transfer to a more appropriate facility was made several times by several people, these suggestions were dismissed, the patient declined further until his oxygen saturation on room air was in the 40% (normal is over 90%), at this point he was transferred …. He died shortly after leaving our clinic not because he received poor care at Dili National but because we waited too long to send him. It was unnecessary and frustrating.

On Tuesday, we returned to clinic with mixed emotions- relieved it was our last day but not looking forward to saying goodbye to some of the great people we have met/worked with. After morning rounds Eva and I went to separate mobile clinics which were both within 30 minutes of Dili. We were back to BPC by early afternoon. I did a few dressing changes in the “emergency room” and drained a rather impressive abscess (about the size of an egg on a man’s neck). On AM rounds we had heard of a patient which was being brought in from the mountains in labor- she was pregnant with twins, had delivered the first twin at 6:30 AM in her home, and was unable to deliver the second twin which was breech (feet first). After finishing up in the ER the ambulance arrived with this woman (about 8-9 hours after the delivery of the first infant). Eva and I followed the patient in to maternity unsure of what had occurred since the AM. While the first twin was doing well, the second one was still in the birth canal and no longer alive- the body was almost entirely out but the arms and head remained. Dr Dan went through the steps of delivering a breech infant with us. With the assistance of suprapubic pressure he delivered the second twin. While the deceased infant was cleaned, dressed, and given to the family, Mom was encouraged to breastfeed the first twin to avoid further complications. It was a sobering moment for all of us. Eva and I finished afternoon ward rounds, took photos, exchanged e-mail addresses, and said our thank yous and goodbyes to the staff and volunteers at BPC.

On Wednesday morning Eva and I, accompanied by Luis (a Timorese friend who lives in Switzerland and was staying across the hall at our hostel while visiting family), went shopping. We visited the local craft market in Dili and wandered through downtown. Tais, which fill the craft market with color, are impressive traditional woven pieces made by the Timorese. We had a wonderful morning and Luis was of tremendous help guiding Eva and I with his insider knowledge. He has become a great friend and resource for us. Wednesday evening Dan cooked dinner in honor of our coming departure… we had vegetable curry with rice, wine, and fresh baked chocolate chip cookies with ice cream (we brought the dessert). Again there was a large group of people at Tracy’s (where Dan lives) for dinner- two Japanese, a middle easterner (didn’t get all his info), an Aussie, a Swiss, a Welsh, and us two Americans.

Our final day in Timor was wonderful! Eva and I set out relatively early in the morning to hike up to a statue of Jesus which overlooks the city of Dili (given by the Portuguese to Timor- for those who don’t know Timor was a Portuguese colony, the vast majority of Timor is Catholic). The views from where Jesus stands were beautiful. We then proceeded to “backside beach.” This is a beach just on the other side of the mountain from Jesus (from the beach you can see his backside… thus the name). To get to the beach we took a foot path which heads down the back of the mountain- backside is supposed to be one of the nicer beaches in Dili because it is a bit harder to get to- less crowded and dirty. We trekked down to a completely empty, completely beautiful beach! It was just Eva and I and a few stray goats for the afternoon. We lazed around, read our books, ate a picnic lunch, and enjoyed the sun. After we had had our fill we trekked back to Dili… it was oh so sweaty!! We met Maggie, the Australian physician who is now working at BPC, for an iced coffee to say goodbye and then headed home to pack. The day ended with Thai food, Bintang (Indonesian beer… the best we have found here), and saying goodbye to Dan (he still has 2 weeks left in Timor). Through all the ups and downs of this experience I think both of us agree we are glad we came. We have both learned a lot… (maybe not what we anticipated learning) and met some wonderful people.

Friday morning our flight left Dili at 8 AM and by 10 we had returned to the developed world… it was a huge culture shock! Generally, in my past experiences anyway, it has taken at least a day of travel to go from somewhere as underdeveloped as Timor to somewhere as developed as Australia. Eva and I checked into our budget hotel (clean white sheets, AC, and our own mosquito free bathroom!!), ate lunch at Subway, and wandered downtown Darwin/the grocery store/shops with wide eyes. It is just so crazy… we live in such excess. Again we headed down to the water front for dinner. Eva was adventuresome and tried a kangaroo burger…. I stuck with a Greek salad- less exciting but still good. Our weekend in Darwin/The Top End (as the Aussies call it) was spent exploring two national parks- Litchfield on Saturday and Kakadu on Sunday. While I won’t go into all of the details we hiked, swam under waterfalls, saw crocodiles/other wildlife, visited Aboriginal sites with rock paintings, and just enjoyed ourselves. The days were long but well worth it.

Currently we are on our flight to Sydney and should arrive early afternoon. A friend of mine from undergrad, Zack, will be flying out of Sydney today so I am hoping we can meet for a quick coffee before he leaves… the plan is for him to be at baggage claim when we arrive. We will then explore Sydney as cheaply as possible (we are staying with a friend of a friend and then Eva’s family). We will be back in Iowa in no time… both of us are anxious to see friends, families, Matts, and our dogs. I think we are also a bit anxious given that Match Day is only 5 days after our return… being in another country is like living someone else’s life for a bit… soon it will be back to reality (which is a mixed blessing). Anyways, hope you have all enjoyed reading the blog and I apologize for being a bit inconsistent in my posting. Much love from somewhere over Australia, Kim

2/22/2010

Filling you in on the last week…

On Sunday (Valentine’s Day) Eva and I met the two Australian medical students (Dan and Liam) at Hotel Timor for lunch, dessert buffet, some pool time, and the hope of free wireless internet. As usual things did not go quite as planned- lunch and the all you can eat dessert buffet were amazing, we snuck into the pool area and lazed around for hours no problem…. the internet however was of course a myth (thus the delay in the last posting and no new picture). I have realized how much I take internet access (on laptops and iphones) for granted at home.

I returned to clinic Monday morning after basically recovering from dengue (although my legs were still covered in a rash for a few more days). I spent last week traveling to a few mobile clinics- seeing around 50 patients in 2 hours at one Eva and I went to together which was a 3 hour drive west of Dili (the evaluation at mobile clinic is very brief and really serves as a means of identifying those few patients who are very ill needing to be brought into Dili for further evaluation/treatment as well as to ensure these communities feel their health concerns/needs are supported). I was able to assist in/observe a few deliveries this week which was also exciting. I have been a bit disappointed in the amount of obstetrics Eva and I have been involved in… the midwives at the clinic handle the majority of the deliveries and it always seems our days are filled with other tasks- unable to just hang out in maternity.

The malnutrition program continues to function and has been greatly aided by the addition of a pediatrician from Australia. Her name is Maggie and she will be spending several months here in Dili. She was excited to work with Grace and I on the program and (as I have hoped to see other parts of the care provided by BPC) she has basically taken over coordinating the daily efforts. We continue to have a large inpatient population of tuberculosis (TB) patients which has been quite interesting. The advanced stage TB presents in Timor Leste is basically unheard of in the United States. Eva and I are both learning a great deal about the varied presentations, treatment, and prevention strategies. Aside from malnutrition and TB patients there are several cases of malaria, dengue, pneumonia, pylonephritis, urinary tract infection, pelvic inflammatory disease, leprosy, mastitis, and gastrointestinal worms.

Last Monday Eva and I were invited to dinner at Tracy Morgan’s home by Dan (one of the Australian medical students). Tracy Morgan is an expat living in Timor Leste working for an NGO… she is fairly well known due to the length of time she has been active in the country/Dili community and because she owns a large home where she houses many foreigners traveling through Timor Leste (Dan is currently living there). The dinner party was in honor of one of the Irish girls living with Tracy and Dan as she is leaving the country to return to Ireland. It was a wonderful dinner and I write about it only to give some insight into the diverse group of foreigners we have met who are here in Timor all working on various projects. There was the Irish girl working for the UN, an Australian working for the police force in Dili, an Australian working for the education system, an Australian working for Marie Stopes Clinic (a family planning center), a Japanese girl working for the office of immigration, a Tasmanian pediatrician, two Australian medical students, two American medical students (Eva and I), and Tracy who is a lawyer by trade. Needless to say dinner conversation was interesting as we enjoyed pasta with marinara and feta, egg plant, garlic bread, red wine, and mango crisp with ice cream for dessert (definitely the best we have eaten since our arrival). It has been great to interact with so many individuals from varied backgrounds.

Now… for the highlight of this blog… and possible the entire trip!! Eva and I spent the weekend in Atauro, which is a small island about 30km north of Dili. The island is 140 sq-km, has a population that totals around 8,000, and only two small cities with occasional electricity. Dan, Liam, Eva, and I all decided it was time to get out of Dili for a weekend and explore Atauro. We boarded a ferry on Saturday morning for the two hour ride across the Wetar Strait. Upon arrival we walked to our accommodations for the weekend called Nemas. Run by an Australian named Barry, Nemas, includes 5 thatched huts right on the beach. We were fortunate to stay in the largest hut which actually had sleeping space for around 8 people and open air bathroom facilities in back. The other huts were occupied by a group of 3 Australians, 2 Portuguese, and a group with 1 Australian and 2 Portuguese. We all enjoyed each other’s company as we dined together in the main hut where Barry and his extended Timorese family live.

After arriving on Saturday, eating a bit of lunch, and getting settled in we spent the afternoon enjoying the beach, reading in the hammock, and playing a bit of Frisbee on the beach. Dinner was served again in the main hut and then the majority of the guests at Nemas returned to our hut for some music. Dan is a talented guitar player and singer (Eva joined in on a few songs and experimented with the harmonica which was great). It was really the perfect ending to an excellent day.

On Sunday, after breakfast and a café Timor or two (East Timor is known for its wonderful coffee), most of us guest loaded in Barry’s small boat for some snorkeling. Having never snorkeled before I was a bit apprehensive but let me just say it was amazing!!! The coral reefs around Timor are supposed to be some of the best in the world and I was reminded over and over again by the other guests how fortunate I was to have this be my first look at life in the sea. We spend several hours flipping around the crystal clear water looking at all sorts of sea creatures… just long enough for both Eva and I to burn our backsides. The remainder of Sunday afternoon was spent in the same manner as Saturday afternoon. I finished another wonderful book in our hammock, the title being “What is the What” and recommend it to anybody looking for something to read. The only downside of going to Atauro for the weekend is the only way to return to Dili is by fishing boat on Monday morning (the ferry only goes for the day on Saturday leaving around 3 PM- not enough time to enjoy the island). So at 3:15 AM Monday morning the alarm went off, all of the guest from Nemas enjoyed one more cup of café Timor together, and loaded in the back of a truck at 4 AM to head to Vilo to catch our boat. The fishing boat was better than I anticipated (we had heard horror stories of foreigners scooping buckets of water out of the bottom of boats as waves crashed over the edge wishing they had a life jacket). Our boat was much different than the image I had in my head. The majority of people stretched out on the deck and slept during the 3 hour trip back to Dili. I stayed awake, saw a few dolphins and flying fish in the early morning light, enjoyed the ride/breeze, and watched the sunrise over the water and Timor. It was truly a wonderful/perfect weekend- great atmosphere and great company. Eva and I returned to BPC refreshed for another week.

This week looks to be very similar to those previous. Eva and I plan to head out to several mobile clinics after morning rounds and spend our evenings with the friends we have made here. We went to the US embassy this evening as a birthday party was being held in George Washington’s honor- turned out to be a standard BBQ by the onsite pool. Eva and I enjoyed a cheeseburger, Diet Coke (for me), and a beer (for Eva) while chatting with several military personal who are working with the Mercy Ship (a naval boat with first class facilities that travels to foreign countries providing medical care). Turned out to be an interesting evening… the US embassy grounds are almost embarrassingly extravagant compared to the surroundings (not sure what else I expected). On Thursday we plan to go out to dinner, maybe Thai, as both Liam and one of the Australian doctors we have spent time with will be returning home on Saturday. Friday is Dan’s 31st birthday (Australian medical student not Dr. Dan) … the plan was to celebrate, however Dan became ill after returning from Atauro… so we will have to wait and see how he is feeling by Friday. Regardless it should be a good week.

Eva and I have booked our return tickets to Australia. We will be spending some time in Darwin and Sydney both before heading home on March 13th. Hope this message finds everybody well... and for those in Iowa while it is scary to say… I miss the snow.

(PS- I apologize for any typos/improper grammar as I have not been proof reading)

2/11/2010, A few bumps in the road...

Since the last post my main project has continued to be developing a malnutrition program at Bairo Pite Clinic (BPC) for the children that continue to come into Dr Dan’s office looking emaciated. The hope is to develop a program that can be maintained by the volunteers and clinic staff after we leave here. It sounds like there have been several attempts at this in the past always ending with a similar story- volunteers come, set up a program, leave, and the program falls apart. Candice, the Australian intern, actually helped establish a malnutrition program here on her first trip to BPC over a year ago. I feel a bit uncertain about how to set up a malnutrition program and I also feel a bit uncertain about how to ensure that it will last.

As a general rule here is Timor-Leste, as in most developing countries, infants receive adequate nutrition as long as they are breastfeed and can avoid illness resulting in diarrhea, vomiting, or poor feeding. That being said when children transition from breast milk to whatever food Mom and Dad are eating many run into trouble. Whether it is the frequency of feeds (which need to be more than 3 times a day like the parents), the quality of food/food preparation, the quantity of food, or any number of other factors malnutrition can become a problem quickly. The majority of the children we are admitting with malnutrition also have complaints of diarrhea, vomiting, and in several cases worms.

With the use of several resources, including the WHO malnutrition guidelines, the advice of two Australian pediatricians, the advice of several volunteers, my fellow medical students, and the clinics nutritionist (that’s right there is a clinic nutritionist…. not sure what else she is all responsible for but I question how you can have a nutritionist on staff and have children dying of hypoglycemia… frustrating) I think we have come up with a pretty good system. It is far from perfect; there just isn’t the staff at BPC to monitor the kids and their feedings as closely as should be done. That being said the kids are eating and gaining weight.

One of the volunteers, Grace, a 19 year old who has recently graduated from high school and is hoping to get a scholarship to study medicine outside of Timor-Leste, has been the best of help. She has been our partner in crime. We weight the kids everyday and hand out packets of what looks like powdered milk called F100. The parents just mix the F100 with 100 mL clean water and feed to their kids every 3 hours. The premixed formula is distributed by the WHO and has all the essentials in the appropriate proportions. We have had several children discharged looking a bit plumper which is promising. One of the children passed away during the night. Dr Dan was not informed until I found out when I had one less kid to weigh and asked the other mothers where she was. Again… frustrating and sad. Really… unnecessary. We have several children in the malnutrition ward that would likely be better served at Dili National where they have a well established malnutrition program with the appropriately trained staff but continue to meet resistance when the suggestion is made to transfer these patients. So we just keep suggesting… and hope for the best.

Now for life outside of BPC… at the end of last week I was sick with what I thought was just a sinus infection (of all things). I was congested, had a headache, pressure/pain over my right maxillary sinus, purulent drainage, and a fever. I started a course of antibiotics, which I brought from home, and stayed in bed except to run to clinic to get tested for malaria just to make sure. I was anxious to feel better so I could accompany everybody to Mt Ramelau for our weekend getaway. By Saturday morning, when we were to depart Dili for the three hour drive south into the mountains, I was feeling a bit better so I loaded in to our rented 4 wheel drive with the other med students. The roads were horrible!! I don’t get motion sick but this trip was enough to put both Eva and I over the edge- up and down, winding through the mountains, avoiding pot holes/sections of washed out road, and just about everything else you can imagine.

We arrived in Maubisse mid afternoon and pulled up to the Pousada, a Poutugesse guesthouse, where we were spending the night. The plan was to hang out Saturday afternoon, enjoy the view of the mountains from the Pousada, wake up bright and early Sunday morning, climb Mt Ramelau, and head back to Dili Sunday afternoon. The Pousada was a beautiful guesthouse tucked in the mountains with gardens and great views all around. Unfortunately, I was feeling rather rotten by the time we arrived so spent all day laying in bed. Eva, the Australians, and the New Yorker played Frisbee and foosball. The air was cool, quiet, and clean in the mountains (very different from Dili). We ate dinner at the main house and I again returned to bed hoping to feel well enough to climb in the AM.

Sunday morning Eva, one of the Australians (the other one was feeling ill), the New Yorker, and I headed for Mt Ramelau at 5 AM. We were able to find the trail head with only a few wrong turns and were hiking up the mountain by 7:30 AM. The hike was wonderful, I was feeling better, and it was so nice to be out and get some exercise. The views on the way up were remarkable and thankfully it remained clear the majority of the way. We reached the top around 10:30 AM by which point clouds had rolled in and we weren’t able to see much unfortunately. The top is marked by a 3m high statue of the Virgin Mary- we took in some sustenance (cheese and crackers, oreos, and bananas) in her presence before heading back to our vehicle. Upon returning to the Pousada we ate lunch and again loaded into our 4 wheel drive for the painful drive back to Dili… this time it rained the entire way. Feeling ill once again by the time we got home Eva and I were in bed and asleep by 8 PM.

This week started just as any of the others have… we were up and headed to clinic for rounds at 8AM. Monday turned out to be a pretty typical day. We went to the grocery store in the evening as we were going to have dinner at Dr Dan’s on Tuesday because the New York medical student was leaving on Wednesday. Eva and I went for Monday night dinner at the Indian restaurant across the street and for some reason I wasn’t feeling quite right. I figured maybe I was still recovering from my sinus infection… so showered and headed to bed when we got home. Tuesday morning I wasn’t feeling much better (dizzy, weak) but again got myself together and headed to clinic with Eva for morning rounds. As I put on bug spray that morning for the millions of mosquitoes I thought maybe I was poisoning myself with DEET (turns out I was wrong). While in the maternity ward I started to feel faint so excused myself and took a seat outside. Dr Dan sent me to the lab to again get tested for malaria and this time dengue as well. Surprise… surprise… I have dengue fever.

For those who don’t know dengue fever is a mosquito-borne virus which is relatively common throughout Asia and thus Timor. There is no vaccine available and they only way to avoid it is to avoid mosquito bites- easier said than done here. Symptoms include high fever, headache, body ache, diarrhea, and some get a rash. Check to all of those. There is no specific treatment for dengue- just rest and take Tylenol for the fever. The other key is to have your platelet count checked daily to ensure they are not falling as dengue can become hemorrhagic. So this is what I have been doing all week... (having the true Timorese experience as many have said). I have been laying in bed feeling lousy and weak, taking Tylenol to try and control the fever, Eva has been drawing my blood every morning to have my platelet count checked at the hospital, and the Australian doctors who round with us on Sundays have been doing home visits to check on my every day. For this I am so thankful!! I have been reading some great books during the day when I am awake to keep my mind occupied. I’m starting feel a bit more like myself but being sick in a foreign place really makes me miss home.

I’m not sure what day I will head back to the clinic… hopefully tomorrow if I feel up to it as I am going a bit crazy in our little room. Eva and I are going to try and go to Hotel Timor (the nicest hotel in the country) sometime this weekend as we heard rumor they have free Wi Fi and an all you can eat dessert buffet… I’ll try and post this blog and maybe a picture or two at the time. Hope everybody has a very Happy Valentine’s Day!

2/1/2010

So… this blog is late but as you will see by the time you get through it Eva and I have been very busy since leaving the States and I have had little time to reflect/write. I will try to start at the beginning and hit the high points. We arrived in Australia in the morning on January 21st. Eva’s first cousin once removed (a stretch I know… but you must be resourceful) picked us up from the airport and was an excellent host for our short time in Sydney. We spent the day cleaning up after the journey, visiting a wild life reserve (so many fun animals in Australia), and having a family dinner with a few other extended relatives. We had a great time with good company. The following morning we flew to Darwin, Australia where we again spent the night before catching our last flight to Dili, Timor-Leste on Saturday the 23rd. Darwin was quite nice… we had “fish and chips” and Australian beer before retiring to our airport hotel (thank you Shiva and Irene). Our flight left Darwin around 6 AM and we arrived in Dili in about 1.5 hours.

As we approached Timor-Leste from the air it was clear we were about to see some beautiful landscape- blue green ocean and beaches surrounding jungle covered mountains. While the island is still largely underdeveloped I don’t see this lasting too long as tourists will surely arrive in flocks at some point. After clearing customs we were picked up at the airport by 2 members of the clinic staff and a medical student from New York who is also working at the clinic. Eva and I were relieved someone knew we were coming… we returned to the clinic in an ambulance to join in on AM rounds.

Bairo Pite Clinic, where we will be working here in Dili, is like a small compound all run by one physician, Dr. Dan Murphy (Dr Dan to everyone here). There are about 6 wards (maternity, TB, pediatrics, malnutrition, and two for general inpatient), a basic emergency room, a pharmacy, a lab, a kitchen, and a clinic where Dr Dan sees outpatient consultations all day. All of the facilities are very basic but seem to serve their purpose. In total there are around 30-50 inpatient at any given time and about 300 patients are seen each day in the consultation room. That’s right… its crazy!! In general the clinic/hospital seems to do good work. That said, there have been several occasions where patient care has suffered due to insufficient resources and man power. Patients receive care for free, both inpatient and outpatient. Dr Dan informed me that the clinic and hospital function entirely on donations, which is quite impressive. Currently, there are 5 medical students and one intern spending time at the clinic- Eva and I, two Australian medical students, the medical student from New York, and an Australian intern. We work well together and have been spending what little free time we have together.

Dr Dan came to Dili in 1999, just as Timor-Leste gained independence from Indonesia. He has remained in the country ever since, working at his clinic despite several episodes of civil unrest/violence. He has gained the trust and respect of many people here. I myself am very impressed with his dedication to these people. That being said… Dr Dan is an interesting character and functions very much as an independent physician. He feels strongly that in the majority of patient cases he knows what is best with little room for outside opinion. He is very hesitant to refer patients to Dili National (the government hospital in Dili which is staffed primarily by western trained physicians with many more resources) as a result of poor experiences he has had in the past. However, when you have a group of medical students who have trained in western systems we tend to feel a great many of our patients would be better served if referred to Dili National where more resources are available (x-ray machine, CT scanners, ultrasound, operating rooms, many sub-specialists, and larger nursing/support staff). This obviously leads to many debates within our group when it comes time to develop a plan of action for patients. It has been frustrating and I often feel we are not doing our best to take care of these patients. I try and remind myself that I have only been here for a short time while Dr Dan has been working in the community for over 10 years. I am learning how to advocate for patients, gain confidence in my diagnostic abilities, weigh many options when it comes to caring for people, and develop a working relationship with a “boss” I don’t always see eye to eye with.

Despite the daily frustrations at Bairo Pite, it has proved to be a great learning opportunity- the pathology we are seeing in these patients is quite different from home. Our typical day, Monday-Saturday, begins with rounds at 8 AM for the inpatients. We usually get done around 10 AM at which point Dr Dan begins seeing patients in his office. As students we either sit in with him, go to mobile clinic (load up in one of the ambulances with a driver, volunteer, and box of meds to travel to a surrounding community), work on the long list of tasks discussed on rounds, explore/develop possible diagnosis for puzzling inpatients, or staff the ER performing any number of minor surgical procedures. At around 4 PM or whenever all the students are available we round alone. When Dr Dan has finished seeing outpatients we check out with him and discuss any inpatients we are concerned about. Check out tends to turn into a lengthy discussion given differing opinions about treatment plans and we wrap up around 6-7 PM. On Sundays we just round at 9AM and tend to leave around 12-1 PM. Physicians from other NGOs, Dili National, and several of the embassies show up for Sunday rounds which make them a bit more exciting. Some of the more interesting diagnoses are as follows:
- Malaria
- Tuberculosis (many cases with extrapulmonary disease)
- Malnutrition, primarily in toddlers (I somehow got roped into helping develop a malnutrition program and have learned a great deal in the last week or so)
- End stage breast cancer without the benefit of western medicine
- Abscesses, which I have had the pleasure of draining… along with several other minor surgical procedures
- Marfan’s with advanced heart failure (no cardiothoracic surgeon to operate)
Again, as has been a theme in the majority of my developing world experiences, the pathology seen in patients is always more pronounced as care/appropriate treatment is not as readily available.

So… what’s it like here outside of the clinic??? It’s hot here… very hot especially coming from Iowa winter. Luckily Eva and I have a window air conditioner in our room at East Timor Back Packers, one of the only hostels in Dili. The accommodations are very comfortable- we have a room with a queen bed, mini fridge, AC, common showers and toilets, common outdoor sitting area, no hot water, and a kitchen for making our new favorite dinner (tomato, avocado, cucumber, and hot sauce sandwiches). We are within walking distance of the clinic and several restaurants including a 24 hour gas station which is quite convenient. The people of Timor-Leste are very friendly and both of us feel quite safe. There is a large UN presence here with foreign embassies everywhere which is a bit interesting to see. Dili’s population is about 175,000 people but there are no high rise buildings and the infrastructure is very basic. (I see all of this changing if the tourist industry takes off- currently there are only a handful of hotels in the area)

While restaurants in Dili serve a variety of food (Indonesian, Indian, Western, Portuguese) many tend to be quite expensive due to the large UN/NGO presence. We have been able to find a few in the area that are pretty decent. We also purchased some basics at a local grocery store (primarily food imported from Australia and China) and are exploring the local produce markets regularly (bananas, pineapple, mangos, avocado, tomato, cucumber, etc). I’m pretty sure you could find anything you wanted to eat somewhere in Dili the question would just be price… for instance we passed on a $10 box of granola at the grocery store even though I would kill for a bowl of cereal. We would likely be more creative with our dinner options if we weren’t so drained at the end of the day… a quick sandwich is just so easy.

With all of the ups and downs since leaving the States I think the highlight so far was Sunday’s adventure to one of the many beaches near Dili. The landscape of this country is truly beautiful and I will be sure to share pictures when I return home with those interested. After rounds on Sunday all of us medical students decided to head to the beach for an afternoon of R&R. I ran to the beach from our hostel and everybody else biked. It was a bit farther than we anticipated on a hot day but this made the sea side lunch/beverages all the more enjoyable. We spent the afternoon swimming (the water was so warm), reading, laying around, and chatting. In the evening we went to a local restaurant frequented by foreigners and watched the final match of the Australian open while sipping Indonesian beer. Had to gear up for another week. J

I think we may try and take this coming weekend off to climb Mt Ramelau, which is the highest point in Timor-Leste at 2963 m. On a clear day you are supposed to be able to see both the north and south coast of the island from the top. The five of us students (our Australian intern has headed to Bali) will likely all go together. I’ll write more in the near future and again apologize for the delay.

Patient Cases at the UHTC and RHTC

The last couple days we have been going to the Urban Health Training Center and the Rural Health Training Center as part of our community medicine posting- we are finally getting to see patients all day every day (and no lectures) : )

Here are just a few of the cases we have seen to give you an idea of the patient population and the health problems they face. Note that most treatment given at these outreach centers is just symptomatic and not necessarily curative.

On Friday at the RHTC I was able to see two elderly women suffering from chikungunya (don’t feel bad if you have no idea what that is- I didn’t until I got here). Chikungunya is a virus which is spread by mosquitoes (similar to how malaria is spread)- the disease was first described in Africa and was very rare until recently. In 2005-2006 there was a widespread outbreak of chikungunya in southern India- after heavy rains and flooding (think standing water and mosquitoes). The virus is generally not fatal although some deaths have been attributed to it. Patients suffering from chikungunya generally present with fever, rash of the limbs and trunk, and arthritic symptoms in multiple joints- can be debilitating. The women I saw both had swollen joints and decreased mobility. The physicians said that the crippling joint pain is the most common and pronounced symptom. The fever generally subsides after a day or two while other symptoms, mainly the joint pain, can last up to weeks or even months (generally longer in older patients). There is no specific treatment for chikungunya- at the RHTC treatment is given for relief of the painful joints- anti inflammatory treatment. (The physicians said that in some clinics steroids are being given.)

A mother and her two sons came to the RHTC- all were patients. The mother had malaria and was given quinine tablets for treatment- she presented with fever and chills for days. Her 3 year old son had a terrible case of scabies and an upper respiratory tract infection. He was given antibiotics, skin cream for the scabies, and advised to take an antiseptic bathe. Her 13 year old son was unable to walk or sit in a chair without assistance. This was the first time he had been brought to the clinic- the mother wanted to know what was wrong and what could be done. After a very brief physical exam and patient history the physician suspected muscular dystrophy. The mother reported that her son developed normally until the age of 7- after which he just got worse. Aside from his physical disability his mental function is normal. He is the product of a consanguineous marriage. The family was referred to SDM hospital- orthopedic department for further care. However, the physician was skeptical as to whether or not they would actually take their son to the hospital (due to a lack of transportation, money, etc.).

Side note- in the past few days I have asked a few physicians about consanguineous marriages in India and why they appear to be so common. Here is what I was told… primarily people don’t understand the medical problems that can result in children that come from a consanguineous marriage (congenital abnormalities). They reported however that the number of consanguineous marriages has decreased to about 50% overall- definitely more common in the villages and rural areas than in urban settings (this is down from about 60-70% 10-15 years ago- the result of education about these congenital abnormalities). The reasons given for arranging a marriage between family members were as follows. Since most parents arrange the marriage and since children generally take care of their parents in old age- parents figure that if both members of the couple are family both have some personal stake in taking care of the parents in old age… thus, the parents are guaranteeing that they will be taken care of in the future. Also, if both members of the couple are individually related to the parents this makes certain that any inheritance will be kept within the family. When the parents die whoever (husband or wife) inherits their land, money, or other property is sure to be family.

Maybe the most disheartening case was one I saw at the UHTC. A 19 year old female came in complaining of loss of energy and fatigue. The patient was clearly anemic and malnourished. In taking the patient’s history this is what the physician found out… the woman had recently lost an infant and complained that her in-laws (whom she lives with- it is customary for the daughter-in-law to move in with her husband’s parents) were giving her a hard time about being an unfit mother. She reported that the family was not giving her any food- she said she had eaten dirt she was so hungry. She said her child died because the family was not giving her enough food to produce sufficient milk for the infant. She said her husband, who works in the field during the day, is not sympathetic and sides with his parents. The physician treated her with antidepressants, nutrition supplements, and advice on free feeding programs in the area.

Along with the above cases there was a woman who presented with fatigue and appeared anemic. After a blood test she was found to have a hemoglobin of 5 (should be around 14). There were countless children with skin infections (the result of poor hygiene)… most of them had scabies and due to scratching the skin had been broken, increasing the risk for secondary infections- which most had (presenting as skin boils averaging 1-2 cm in diameter). Oh and a family of 5 all suffering from gastroenteritis- mother, 7 year old son, 3 year old son, 2 year old daughter, and 7 month old daughter. The physician treated them with antibiotics, oral rehydration solution, and a stress on personal hygiene. And on a more positive note today a 98 year old woman came in to the RHTC, after walking 2 km from the neighboring village, to inquire about getting some new glasses. She had broken hers and wasn’t able to see very well with the old pair she had found at home. Aside from the glasses request she was healthy (and probably the cutest old lady I’ve seen- Eva and I took her picture) : )

Our days spent at the UHTC and RHTC have been an amazing opportunity to learn about medicine, about healthcare in India, about treating a patient population with limited resources, and most importantly about compassion. I feel fortunate to have been able to see and learn from patient cases that are not likely to appear at the University of Iowa Hospitals and Clinics.

Just a few thoughts…

So… this post is just going to be lots of things about our summer here in India and a little bit about our posting in community medicine (more to come later).

I knew coming to India that most Indian marriages are arranged… however I was totally unaware of the process behind arranging a marriage. While times are changing and more and more young people in India are meeting their mates in their own way- opting for “love” marriages (especially in the large urban areas) – here in southern India the majority of marriages are still arranged. Eva’s aunt and uncle are currently helping their nephew interview prospective brides. This past week Auntie and Uncle, as well as, mother and father have traveled three separate days to cities around Dharward to interview girls and the girls’ families. We inquired about the process and this is what I have found out….

First the parents of the man consult a matchmaker to learn of possible brides. They then set up meetings with these girls and the girls’ families for a sort of interview process. There are generally multiple meetings before a decision is made. If the families agree that the couple is a good match they then consult a fortune teller. The fortune teller must check the horoscope of both parties and give the union an “all clear” before the couple can be married. In some cases dowries are still given in the form of money, gold, a car, etc. (of course all situations are a bit different… this is just what I have gathered thus far). If it is decided that the couple is a good match it is at this time that the future bride and groom are able to communicate- get to know each other (alone).

Eva’s uncle explained that not only must the woman and man be a good match (caste, horoscopes, height, beliefs, future plans, etc.) but the families must fit together. Generally, after the couple is married the wife will move in with the groom’s family (most homes here are multiple family dwellings). She will assume the household tasks given to her by her mother-in-law. I don’t know a lot of details about the actually marriage ceremony (it is supposed to be quite the production- generally between 1,000- 2,000 guests)… Eva and I have been invited to attend the wedding reception of one of the physicians from the hospital. The doctor is in forensic medicine and will be getting married this Sunday. It should be an interesting event- we will be wearing saris to the reception.

Now I mentioned above that part of a couple being a good match is being members of the same caste. The caste system is the basic social structure of Hindu society and although it is not as strong today as it once was… it is definitely still present. For example, here at the house there is a girl, about 12 years old, named Lakshmi who helps Auntie with the house work. She is actually the daughter of the family who farms the land owned by Eva’s family (if that makes sense). Lakshmi lives here at the house and attends school in Dharward (which is a better school than the one she would attend growing up on the farm)- she helps cook and clean in exchange for room and board you could say. Even though the family likes her very much, she is a member of a lower caste and thus eats off of different dishes than we do and sleeps on the floor near the stairwell (even though there are about 6 empty beds in the house). Our driver, who takes us to and from the college everyday, is also a member of a lower caste and thus takes his tea out of different cups than we do. It is all very strange to me.

I, being totally unfamiliar with the details of this system, did a little reading in Lonely Planet… here is what I found out. In Hindu society there are 4 castes and below these 4 main castes are the Untouchables or Dalits (menial laborers- sweepers or latrine cleaners). The castes, from top to bottom, are as follows- Brahmin (priets and teachers), Kshatriya (warriors), Vaishya (merchants), and Shudra (laborers). It is thought that if one lives a moral life it is more probable that one will be reborn into a higher caste with better circumstances. Again, in India today the caste system is definitely weakened and far less rigid… but its presence can still be felt.

Eva and I have been enjoying Indian television in the evenings… there are about 3 channels in English. The channels actually broadcast some descent shows… Seinfeld, Friends, Scrubs, Arrested Development and some alright movies. However, more fascinating than the shows are the commercials. It is interesting all that can be learned from a society’s advertisements. For example, there is a commercial (which airs repeatedly) for men’s face wash… and what makes this face wash special is that it whitens your skin. It is called Nivea White for Men (sp?). So…. while Americans are spending loads of money trying to achieve that sun kissed summer glow… Indians are spending money on face soap that will make their skin whiter. There are similar advertisements for women’s face wash. Whiter skin is desirable because it says something about your social status- if your face is light you must work indoors and make more money than the dark skinned man who works in the sun as a laborer.

Onto the next topic… Eva and I have noticed a difference in the maturity level of the second year medical students here at SDM and the second year medical students at the U of I. For instance, the other day we sat down the in a classroom in the Department of Pediatrics with the batch of second year students we were posted with. Eva and I sat in the middle of the second row. Instantly all of the students moved their chairs behind us and one another so that they would be in the back of the classroom, farthest from the professor. Come to find out the medical education system is a bit different here in India… making the age of the students a bit different. In the States, after completing 12th grade, one must earn a bachelors degree (4 years), then attend medical school (4 years), and then complete a residency program in a particular specialty (minimum 3 years)… after this you are a full fledged doctor. In India, after completing 10th grade, one must attend college-11th and 12th grade-(2 years), and then medical school to earn a bachelors degree in medicine (5.5 years including internship)… after this you can practice medicine. There is the option in India to do a postgraduate degree in order to become a specialist (three years). What this basically all means is that at age 23 (my age), I would be practicing medicine already in India, rather than having at least 6 more years to go in the States. At home we must attend 11 years of education (minimum) after 12th grade to become a doctor. Here in India it is just five and a half years after 12th grade. So our fellow 2nd year medical students at SDM are on average 18-19 years old… this would explain the boys punching each other in the arm while the girls are trying to interview a patient : )

We are nearing the end of our time here in Dharward and are in our last posting- community medicine. While it has been a bit of a struggle conveying to the department that we want to spend as much time seeing patients as possible (and as little time in lecture as possible- the Head of Department designed a two week lecture schedule for Eva and I specifically) the posting has been very interesting so far. The Medical Council of India requires that all medical schools in India provide an opportunity for their students to learn about community medicine by establishing and staffing an Urban Health Training Center (UHTC) and a Rural Health Training Center (RHTC). These centers are basically outreach clinics which provide extremely affordable healthcare to the citizens of the lowest socioeconomic class. Patients pay 10 Rupees a month (a quarter) for unlimited treatment at the UHTC and 5 Rupees a month at the RHTC. While the clinics are by no means all encompassing facilities… they do both have 2-3 exam rooms, a small lab (to do blood and urine tests), a pharmacy (all meds are free after the monthly fee has been paid), and immunization programs. If a patient requires further care and is unable to afford the services of SDM Hospital (it is a private facility) they are referred to the free government hospital in Hubli. Each center is staffed by about 15 people (5 doctors) and serves a population of about 30,000 people. The centers are open from 9 AM – 1 PM (6 days a week) during which on average between 80 and 120 patients are seen. The UHTC is located near the slums around Dharward. The RHTC is located in Wayadad, a village of about 3,200 people about 40 minutes drive from Dharward.

Our last day at SDM will be Thursday, July 12th. On Friday Eva and I will take the train to Bangalore. We will be spending the weekend with her uncle in Bangalore… and possibly taking a day trip to Mysore. On Monday, July 16th we will fly to Delhi for a North India Highlights tour (visiting Delhi, Varanasi, Agra, Jaipur, Jodhpur, and Udiapur). The tour will end in Mumbai on July 26th. We will then do some sightseeing in Mumbai (hopefully take in a Bollywood movie or two) before flying home the night of July 31st. I am not sure what the internet access will be like at our various destinations… and seeing as we are moving cities almost every other day… I can’t guarantee updates on my Blog… but I will try : )