"I was yellow, and really tired"

Today we were practicing our questionnaire on inpatients again before we start the actual study.  The patient we met:

Male, age 54, came in for yellowing of the skin and extreme fatigue for 8 months.  Recently with palpitations, not able to walk a city block. Recent nausea, vomiting.  No past medical history, and certainly no history of Chagas (we had a lot of Chagas questions).  He explained he was getting treated for anemia, and had some parasite eating his blood.

We looked at his chart to fill in some gaps.  He came to the ER with surprisingly normal vitals, and his hemoglobin (red blood cells, they carry oxygen and are quite important) was 2.6.  No, not 12.6, which is the average for the population.  Check out this chart to see how far off he has fallen, and how most people at that level would be long dead.  Eosinophils 10.  He two tests where people looked in his stool with a microscope, one which found the parasite- Strongyloides stercoralis.  He was transfused red blood cells, and is doing well now, awaiting confirmatory tests (likely culture of stool in agar) before starting treatment.

An equally likely explanation was the hospitals labs were off, but I don't think that's the case here.

El Uno Por Ciento

So when I thought of coming to Bolivia, I had my ideal life in mind- slow, pacified, and most of all simple- washing clothes in a sink, hanging them to dry, cooking on the stove, settling into bed early.  Living like the people.

As before, our friend Omar graciously wanted to help us find an apartment he deemed safe for us.  Which eliminated, well, most all of the city except for a few pockets.  Dappled around are “mercados” or markets where people set up cheap stands and bargain, creating dangerous pockets at night.  And no where outside the second ring was safe enough.  And definitely no small houses for us, since we are too easy targets.

We found an apt for $700/mo, a little more than we had budgeted ($650/month).  And it was a dream apartment for anyone.  Pool, grill, and playground outside.  Gorgeous furniture, huge kitchen with a microwave.  Three bathrooms, two bedrooms, washing machine.  Living room the size of a NYC apartment.  And beyond safe, in possibly the poshest area of town that looks like any modern day strip.

I can’t complain.  I really can’t.  But there is a more than a twinge of guilt when you realize a month’s rent is over twice the normal salary of an average office worker here.  I am “el uno por ciento”, literally "the one for hundred", or as our friends at OWS have popularized, "The 1%".

Pizza Cones!

One day I will write all about the wonderful Bolivian food, but Jackie and I had a really long day yesterday coordinating how our study will run and all our samples, so we really just wanted fast food.  And pizza cones were 2 for 1!  Here's the nice super upscale part of the city:

Ease of eating: 4/5 - fun to pick up the cone, but far too disproportionate filling at the top
Flavor: 4/5 - love the ham and corn flavor, cheese is different... local and very stringy!
Cost: $1.25 each (vs beers were $2 each)

The Apartment Search

the local 75 cent paper

On our first weekend here, we decided to go apartment hunting.  We have been staying at the lab house which the researchers rent out to keep frozen samples and extra twin beds.  NYU had been wonderfully generous with a stipend for living, and we had been recommended by others to spend $500-650 for a decent place.  Apparently, though there isn’t much crime surrounding it, the cocaine industry has driven up prices drastically here as wealth is now possible.  There are still tons of places for $300, but just not safe to have a laptop in.

check out that Sunday afternoon
 eyeshadow and fake lashes

Our first place we saw was a stone’s throw from the third ring (the city is concentric circles).  There was a bus straight in towards the hospital, and the place was very modern with a guard.  The neighborhood was just that- a real neighborhood.  It was perfect, and reasonable at $600/month.  And we found it ourselves!

We told our local friend Omar about our prize.  He seemed shocked- the third ring was a little too far.  So we asked him to drive us back when it was dark (anytime after 7pm, thanks to the proximity of the equator).  There were no lights, and the neighborhood seemed more like just a ’hood.  “GET OUT JACKIE!  WALK AROUND NOW WITH THOSE KIDS!” he joked as his scare tactic.  It wasn’t terrible, but not somewhere for a white girl and her laptop.   So, back to the drawing board we go.

Neighborhood by day, not a place for 2 gringas at night

Failed Interview

So right now Jackie and I are trying out our questionnaire before we start the actual project and data collection.  We are changing words like "hypertension" to "high blood pressure", and making sure our data will be relevant and reliable.  We have interviewed a few patients, but it is very difficult as our Spanish is not yet up to speed and the older folks from outside the city are quite a difficult interview.

Jackie had interviewed a very nice young man Pedro*, age 24, who spoke pretty clearly and could answer questions without too many tangents.  When we read through his chart later, we found in his social history that he has been living in the streets and various places since age 10 when he left his parents house.  Imagine that.

I went a few beds over to a much older gentleman.  We introduced ourselves, and he told us his name.  We asked if we could do this questionnaire, and he seemed to agree and started talking about his nausea.  After expressing some understanding, we decided to start the questionnaire.  "What's your birthdate?" I asked for our demographics section.  He pointed to his ears, then started talking some more about things and his nausea.  I decided to skip that question and try the next.  "What provence do you live in?".  He went out about nausea.  I repeated the question, but he indicated he couldn't here me, so I was shouting the question.  Then shouted the next question.  This guy seemed to be really confused.

Several times he repeated a small phrase, and I had studied it just days before, but in the moment my mind blanked and I had let it slide as something about his nausea.  "Soy sordo" he said again.  And finally I realized what he was saying, and why Pedro across the room was dying of laughter at this point.  He was saying all along "I'm deaf."

*not really his name.  Not sure of the HIPPA equivalent of Bolivia, but we will function on U.S. standards for patient privacy.

We came to Bolivia... to go to a NYC club?

Last Saturday we had our first night out in Bolivia.  We have one Bolivian friend from the project, Omar, who is a fantastic guide and offered to take us out.

Jackie and I were expecting the usual- lot of Latin music and hip shaking which we would meekly try and keep up with.  Instead, we walked into a posh club with a huge picture of the NYC skyline surrounding the entrance.  And a cover- 70 bolivianos/ $10 (the cost of about 5 lunches out at the local places)!

Inside it looked exactly like NYC Meatpacking District- dark, posh couches all with bottle service, abstract art and huge chandelliers, and American pop remixes blaring. Wasn't I trying to get away from this? We wore jeans, but every other girl had on mini dresses and 3-inch heels.  And they were trying to dance like Americans- all arms and torsos! The cherry on top was hearing Shania Twain's "Man I feel like a woman" followed by "We will rock you". Finally around 1 am, there was a radical switch to Latin music, and everyone got up and really started dancing, hips and all : )
(This picture is during the U.S. music, where no one was really dancing at all)

Cheers!  (smiling at the irony of it all)

We got pimped.

For those not in medicine, pimping is when you are going around with the doctors/residents and they start directing difficult questions at you, mostly making you look like a fool.  It's a real problem in Spanish.

We haven't started our study yet, but are going to morning rounds on the men's medicine floor just to show our faces and get some idea of the patients.  We can't hear 70%, and we can't understand most of the other 30%.  Yesterday, we were going over EKGs of a patient when the doctor suddenly turned to us and asked if we knew what the "eje" should be.  We just blankly stared back.  After visibly dripping sweat for what seemed like minutes, I just said "no".  Everyone was a little shocked, and he assigned the intern to teach us about it.  Until we realized "eje" meant "axis", which everyone learns in the first lesson on EKGs.  Sorry U.S. medical schools, we failed our reputation of being any good.

The next day, the same doctor was pimping the Bolivian medical students.  He then turned to us.  We shyly and slowly asked in our broken Spanish if we understood the question: the cardiac signs of anemia.  Easy!  I said "tachycardia" and Jackie jumped right in for "ejection murmur".  Bam!  Reputation somewhat restored.  We later gave the list of indications for cardioversion.  The Spanish is tough, but oh so rewarding.

Here's the pictures that Jackie, Omar (great Bolivian MD working with the research group), and I took for our hospital IDs!  I finally cut my hair short a month ago, and if anyone is interested I really believe Pantene Beautiful Lengths is a great organization for a hair donation with a lot of NYC salons which will cut for free.

So I arrived safely in Bolivia!  It was a long string of sojourns and 3 planes (JFK--> Bogota, Bogota--> Lima, Lima--> Santa Cruz).  Nate rented a really old-school BMW from zipcar for $30 and drove us to JFK in style : ).  I was on the Colombian airline Avianca so everything was Spanish from step one.  I actually enjoy airline food, and now those are true portion sizes, America!  To prepare, I watched the cartoon movie Pirates in Spanish; it's pretty silly and fun.  The whole travel time, particularly the slow and inefficient immigration and customs, took about 23 hours door-to-door.  

Each step your bags go through security again.  In Bogota after scanning my bag, then searched it for a good 30 seconds.  I was preparing answers to the dozen questions on explaining why an EKG is not a bomb and why I had one in my bag.  Instead, they just found and confiscated a roll of masking tape I had!  Apparently, tape is a dangerous weapon in Colombia.

I applaud the truly fair and random system of choosing which bags to search at customs.  And it's like a game show!  There is a red light and a green light which are randomly sequenced after you hit a button.  Step on up Emi!  Drag your 2 suitcases and carryon while holding a passport and 3 forms!  Then press a button and.... BZZZZT  red light- you get your bags searched!  Luckily the Bolivian lady (in heels and the shortest skirt I've ever seen in an airport) who was doing the bag search only made me unzip the bag, rezip it, and get on my way to see Bolivia.
I couldn't take out my camera, but this is what the lights at customs look like.  Also I arrived 8/16/2012, but just getting around to posting something.

Ten Frequently Asked Questions

(1)  Why Santa Cruz, Bolivia?

Per Horace, carpe diem.  It’s my chance to finally learn Spanish, truly experience the culture, and challenge myself.   Chagas disease is most prevalent in Bolivia, as the other countries in the Southern Cone have already taken big steps towards eradication of the disease (mainly housing improvement).

(2)  What is Chagas disease?

Chagas disease is caused by the parasite Trypanasoma cruzi.  It is carried by the reduviid bug, known as the “kissing bug” or "vinchucha" (see wanted ad on right).  After biting, the bug leaves behind feces with the parasite, which is then scratched into the wound or mucous membranes by the host.  Over years, the parasite causes dilation of the heart and intestinal track, with 30% progressing to heart failure or sudden cardiac death.  Treatment with nifurtimox or benznidazole is very toxic, so the risks vs. benefits is currently under investigation.

(3)  Who is this Jackie Sherbuk?

Trusted friend, classmate at NYU medical school, and co-explorer extraordinaire.

(4)  What will you two be doing for research?

We will be working in conjunction with the city’s largest hospital, enrolling presenting patients and performing EKGs, echocardiograms (heart ultrasounds) and blood tests for biomarkers of cardiomyopathy (BNP, troponin, MMPs, antigen PCR, etc).  Ideally we can use this information to determine how best to identify patients at risk for heart disease.  Our project is under the auspices of two great principal investigators, Robert Gilman of Johns Hopkins and Caryn Bern of CDC, who will periodically visit the sight.  Two MDs will be fully on site helping.

(5)  What’s the weather like?

Hot and humid year-round.  It’s a subtropical climate with the Amazon on the horizon. 

(6)  Where will you live?

A modern apartment with Jackie.  With air conditioning.   No reduviid bugs.

(7)  Will you get weird diseases?

As per CDC recommendations, I’ve been vaccinated against yellow fever, typhoid, and rabies now.  Malaria is low risk in this region and rarely seen.  I’m guessing dengue is most likely of all, in which case you’ll hear about it.

(8)  Will you get Chagas disease?

No.  The reduviid bug lives and bites only in the worst housing conditions of the rural areas- mud walls and thatched roofs.  Besides, I promised my dad I wouldn’t.

(9)  What about Nate?

He is staying in New York and will continue writing and being Nate (read some stories here or here!).  Hopefully he can visit twice, and we both are planning to make a friend’s wedding in London this year.

(10)  When are you returning?   
Now we are scheduled for May 30, 2013.  See you then!

en mi vida

For all those that asked and the many more that didn't, here's my latest attempt at a blog. First step is a title, and I'm choosing one of the great Beatles songs, "In My Life". click to listen