Costa Rica means "Rich coast", but that is an inexaustive list of what costa rica is rich for. Other than beaches, it is rich in mountains, reefs, volcanos, green everywhere, you-name-it-we-got-it list of wildlife, happy and friendly people, and a weather that is less than 65 degrees on a bad day. It is not very rich in rich people, but that is ok. I am waiting in the bus station 50 kilometers west of San Jose, in a city called San Ramon. it is sunny and humid, and a natural breeze is cooling me off. I started working on my tan. across the street they are selling coconut juice in a small plastic bag. 50 cents will get you this delicacy . I am still amazed by the sights I saw on my way here. honestly, I didn't know green had so many shades. I saw banana trees on top of a hill next to a lake. every five minutes a stream or lake would come into view, with the hills clearing up and letting you see miles and miles away. the houses are modest and gorgeous. They are painted with lively colors of hot red, warm blue, or questionable pink. cows, horses and donkeys just hang out, lay down and munch on some grass. they really dont have to put so much effort, just chew. and they are. there are a million types of plants whose names I dont know. a bunch of trees were duped from getting sun, because they grew up in a valley. no problem. they are just growing taller and taller, now surpassing their buddies up the hill, their green leaves hanging and bathing in the sun. a guy is building his house right on a stream of water. does anyone care? there is another one just up the road, and another one after that, and another one after that. no problem. people do seem happy and content here. I cant quite blame them, as they live in heaven on earth.

living with a mental illness is very hard. I mean, err, it must be hard, or so i've heard. or so it seems like, ahm, yeah. Not only you have to deal with your own limitations and concerns, you also have to deal with people's reaction to you. and then, if you are obsessively concerned with aliens, think you are about to discover the secret of life, or just keep hearing bob dylan talking to you, you can't quite take care of you health issues, right?
so you don't brush your teeth as vigorously as you used to, and shower becomes an option. and then you might skip a meal or two, and sometimes sleep on the street. and then street actually becomes your home, so you shower even less, and you sleep on benches, which can't be good for your back, and some teenage punk kids might decide to torment you a little, just for fun, since it goes well with alcohol, and you might end up in the ED.
Or, it might just get cold outside. and you don't have a home. and we have blankets.

We are not quite sure where Mr F fits in that list, but we suspect it is all of the above. Regardless of cause, and despite the fact that Mr. F has not voiced any particular affinity to Bob Dylan, he walks through our door on winter nights and complaining he can't swallow his own saliva.
Now, this is an important point, because it is not that Mr. F can't swallow anything, like food, beer, insects or feces - he is handling these quite fine, but it's his own saliva that he just can't swallow.

He is a tall and thready gentleman, with extremely bad dentition. he wears the same clothes, usually, and somehow he always seems to end up in hallway bed number 1.
If you ask Mr F, he will tell you that he is perfectly normal, and does not quite understand what people want from him. he just can't swallow his own saliva, no matters what his voices are telling him. He is a very calm and gentle man. he waits in his bed patiently until a doctor sees him, he patiently (and repeatedly) would tell the poor-new-intern-that-doesn't-know-him-yet the story of his life, and of his saliva, and then, lsiten carefully as the doctor tells him that he is alright and that he can go home. he nods, understanding, and comes back the next day.

My colleagues would probably kick me in the head for this, but in a way i hope Mr. F will keep coming back during those winter nights so we can check his swallowing problem. I am not quite sure where he sleeps at night, and at least that way we know he is safe.
It's not easy being a schizophrenic these days

Patient number a-15902 is lying in bed 10 and thinking about death. There is not much news in that, she has been thinking about death for the last 6 months, but for some reason, death doesn't seem to be thinking about her. sometimes it seems like it is finally coming, but then, like a bad dream, she is consciouss again, feeling everything and thinking about everything. I am dying to ask her what she is thinking about all this time. we are used to her being invisible. she is very quiet, as intubated patients tend to be, and usually they are also totally out. she isn't, however. she can hear everything. that is about the only sense she has left, along with the hopefully-worn-down-by-now sense of pain. today is a big day for her. we cut a hole in her throat and put the tube there, instead of going through her mouth. we really, really didn't want to do that. we even managed to extubate her a couple of times. but she just couldn't breath properly, and had to get on the tube again. and now there's a hole in her throat.
"water", she moves her lips quietly, unable to make a sounds, and i really, truly feel that I want to die. "just a minute mrs. K", and I soak a gauze-on-a-stick with water and let her suck on it like a popsicle. that is only one of the bonuses of removing the tube from your mouth and placing it right through your throat - you can start tasting things again. she is nearly ripping the gauze off in thirst. She definitely wants more. I am looking at her tatooed patient number, a-15902, and wondering if she ever experienced thirst like this over there. I want to ask her about that as well, but she wouldn't be able to answer. I would give her a pen and paper to write on, but she is totally blind. well, at least in europe she had her vision. at least that.
she gulps half a glass of water using the gauze-on-a-stick technique, and I am getting a little worried. I don't want her to aspirate anything in her lungs. for the last 6 months she has been poked twice daily, at least, using ugly needles, and sometimes tired physicians. she then had half her bowel removed due to an infection (caused by antibiotics we gave her, by the way). she then went on and off the tube a couple of times, each time getting it back, each time emergently, without being too cautious about lacerating her lip, or breaking her tooth. then, just as a cherry on top, she got a hole in her throat. It would have been great if her husband could at least come and support her, as he had for the last 30 years, being her cane and her eyes, but he is dead now. he died in the same car accident that kept her alive, conciouss, aware and remembering. She never had children, and the only family member sniffing around keeps asking us if we think she is going to survive because he needs to take of her finances. Why don't he gauze-on-a-stick a little, instead?
I am thinking about Job right now, and his dedication to god, and the torments he went through, and I have a feeling he would long be pagan if he had to go through what patient a-15902 went through. they say women are tougher than men, but this is just too much. If Satan was a doctor (not a very far fetched theory), this is probably what hell would be like.
We do try to treat her pain, really, realizing it's here to stay for a while, but then we might not be giving her enough, and it's not like she is saying anything, or protesting against the damn needle down her artery. on some days she is too feeble to resist, and in others, you have to hold her hand so it wouldn't withdraw once you poke her. I am actually doing it right now, and her tatooed number is looking right at me. I am going for her artery, right between the '1' and the '5', and I am wondering what was it like when they tatooed that number on her. did she resist? was she too feeble? she had her eyes back then, does she remember the tatooer? does she remember me?
She takes advantage of the nurse not noticing her for a minute, and tries to make a run for it by pulling the tube from her throat. the machine starts beeping. "stop it!" shouts the nurse, a very patient one on most days. I think he was concerned about her hurting herself more than anything else. he ties her hands and puts everything back into place. I go up there and her eyes are red and tearing. The lady means business. she does, indeed, want to die. the sooner the better, and everyone seems to have the same sentiment. why is she still with us then? we had younger patients, healthier patients, anything patients, who passed away. So why her?
I think about Mrs. K every day after work, and before I go to sleep. It seems like the ICU keeps reaching new peaks of human suffering, or maybe it's just the same peak all over again, what do I know.
I only know that I am not sure what force of life keeps Mrs. K going. I don't know if this is a story about the human spirit or just human misery, about indifferent doctors or about the futility of medical treatment. in fact, there may be no lessons to be learned from this, but just to tell its tale, and let you know, that there are people out there like Mrs. K.

Home

i am driving through heavy traffic on my way to work. the woman next to me slows down further, brings down her window and shouts across the road: "sarah!"
a woman across the road slows down her car, opens a window and says "Hi! how are you?"
"Good, and you? Have you heard about Esther?", she puts on a sad face.
"Yes, I went to the funeral", the other woman has a sad look as well.
"Ok, see you later!", they both smile and drive away.

To me, this little encounter is incredibly Israeli. First, they slow down traffic for a quick hello. second, within a second they go on to talk about death, and then it's all good again, and then they drive off.

that's how, on my first day in Israel, I knew I am home again.

The bloody connection

During the first hours of labor and delivery the miracle of life escapes your eyes. There is a puffy, bloated woman there that is clearly either uncomfortable or in agonizing pain. She can hardly mount the bed and then you plug this weird thing to her belly to measure all sorts of things. And then the fun part comes, where you take two fingers and insert them where they need to go, and now comes the dramatic part, the pinnacle of every obstetrician's professional life - how is the cervix doing!

Well, he is doing fine, thank you very much. He is sometimes soft, and sometimes hard, he is sometimes dilated, and occasionally effaced. If you are lucky to get more involved in the drama you might feel the baby's head way up there (or way down there if "baby comin' out").

When Mr. Cervix is impressive enough the poor woman is cordially transferred to the delivery room, where the miracle takes place, but not just yet. first she is in a little more agonizing pain. some want pain medication, some want an epidural, some want to feel it all the way to a stress ulcer.

And then the amniotic sac ruptures (if it hadn't before), and then baby comin' out, but not quite yet. first she needs to feel that she needs to push. that, too, is very important. how do you know you need to push? oh, you do, believe you me. It's like a bowel movement, and funny i'm mentioning that, because baby is not the only thing coming out.

This is actually a dual process. two separate entities are actually seeing the light of day for the first time, and occasionally one might get confused on which is which. You see, the most repetitive process during labor and delivery is wiping a pregnant patient's behind.

And now comes the times to push.

So she is pushing, and everyone around her is hysterically encouraging her to push push push push, and push she does, and there you see a little bit of hair.
"let's lubricate", says the wise midwife, and a nurse pours incredible amounts of a vaseline-equivalent, which she smears and rubs very proficiently in the vaginal canal.
baby almost comin' out, but not just yet.
So she keeps pushing and pushing, and you take her legs and pull them almost all the way to her head and around her neck, and you implore her to push, to not give up, just a few more pushes, and people count to ten, and people count to twenty, and baby slowly comin' out, and Mr. Turd during a much better job at it, and nurse wipes it, but then she forgets, and that piece is stating right at you, and at some point you take a piece of gauze and give it a good wipe, and now you know you've done your time. and the the contraction ends and everybody relaxes for a bit. you hear the fetal heart tones and know they are not too slow so that's OK, and you look at the monitor and see that things are fairly in order, and not two minutes pass and there's another one coming up!
"push, push, push!", an excited family is shouting cheerleader style, I can almost see them going "give me a P! give me a U! give me an S!" and so on, and the poor woman is pushing and pushing, and Mr. Turd is actually beating Mr. Baby again, but baby's on his/hers way out, that's right, he/she is right down there and comin' out.

It is very symbolic that birth is involved with so much shit. it's almost like god is telling you, kind of very subtly hinting you, it's going to go hand in hand from now on. don't you be expecting any good stuff without a good dose of crap with it. However we don't quite seem to get it, we don't even remember that Baby-Turd race until we find ourselves in the delivery room, and something kind of sort of feels familiar.

another contraction.
and she's pushing. and pushing, and it's really quite incredible an entire head can fit right in there, which makes you feel a little incompetent. and baby's pushing against vaginal wall and it looks like he's going to make it this time, but not quite. mommy's pushing pushing pushing, but then needs to rest. we need another contraction.
and another one comes along, and baby's pushing, and slowly, gently, almost there, and you support the head so it won't pop out too quickly, and gently, baby pops out, and leaving that remaining turd way behind. it's looking to the side, my right side this time, and I grab him by the neck, my god this is scary, and I make sure there is no umbilical cord around his neck, like I had when I was born, and then I pull on him a little, and I pull him outward and downward to deliver his/hers upper shoulder, and I pull a little longer and this time upward to deliver the lower shoulder, and then head and shoulders coming out, and all that's left is to give a little tug and entire baby's coming out, and he looks dead.

but they often do, and sometimes they look blue, too. and a good rule of thumb is that pink baby better than blue baby, and you immediately start ticking him off, you rub his belly really strong, and you stick a nozzle in his nose and mouth to vacuum secretions, and after a few seconds there is usually a cry, and you want to cry with him, because you have been working too much and have been around for 30 years (my god has it been that long?), and so you really have something to cry about. but instead you clamp the umbilical cord one time close to the baby, and then one more time a few inches up the cord, and then you might let the dad cut in the middle, if there is a dad around, or maybe a grandmother, or whoever, and then baby is ready for shipment. and next stop is little baby thingie in the corner of the room, with the nurse waiting to tug on his and annoy him a little longer, and after that give him to mommy for warmth and breastfeeding and just bring mommy and baby together. but for this you have to carry baby, who is slippery anyway, and wiggling as well, on your bloody gown from mommy's stuff, and you are terrified that right then and there baby's gonna splatter all over the floor, and you are going to hit the news, and he will sue you when he's older, and you will harm him, and after all he just got here. but then you overcome this fear, and you hold baby real tight, you grab him by the ankles and support his head, and you bring him close to your bloody gown, and you say "please god don't let this thing drop off my hands", and these three feet seem like a half marathon, but eventually you make it, and you put baby in his baby bed, and you say thank god, and you go back to mommy, and now the battle of the placenta commences.

the battle of the placenta includes you, mommy, and a pair of clamps. you see, baby coming out is really nice, but delivery is not over just yet. Ms. Placenta is actually part of baby, and like any chick, she is taking her time, she might take up to 30 minutes to come out or even longer, and like any chick that's getting ready to go out, you better not rush her, otherwise something bad is going to happen. so you are giving little tuggings to the umbilical cord, just to see if she is ready yet, and you hold the uterus on her lower abdomen so it won't come down along with her, and you give the little tuggings, but placenta ain't comin' out just yet. she needs her time. so you wait there with the clamp clamping the umbilical cord, and your back hurts by now because you are bending forward all this time, and eventually, when you give a little tug, you can feel it giving way, and then you put a bucket underneath and you tug on placenta as she moves, and lotsa blood comes gushing out, and now it's time to give a uterine massage, a deep, decisive one, so the uterus will constrict, and there won't be as much blood coming out, and also to make sure everything that needs to go out will. and you give that massage and you check the placenta, that everything that needs to come out really did, and then you tell yourself that delivery is over, but we are not over yet, because now comes damage control.

so there is a lot of pushing going on during delivery, you could call this the defecation of your life, and a lot of pressure, and an entire baby coming out of there, so you can understand why there might be tears and bleeding and stuff like that, and some of them need to be fixed. so you need to check all over there if anything is bleeding, if anything is torn, and you might want to suture that, so there will be no bleeding, and also to keep the husband happy, and of course to keep mommy happy, because you don't want her to curse you all her life, because you never know which one of those actually work.

and after you have done your laceration repair you take all the fluids and blood and tissue and shit and you wrap it in a big plastic bag, and you put it on the table and you tie everything nicely, and you tell mommy "felicidades" and they shake your hand, and they are happy, and you are kindda happy, although you still have to stick around until the end of your shift and you are tired anyway, but then again, that's life, right?

And then I see my name on the poor thing's birth certificate, and now I know he is branded for life, and that he might come get me one day, when he is all depressed, and fed up with it all, and probably wishes I shove him back in there, because i'm the first person to see him out, but to tell the truth, I can't help a smile in the corner of my lips, because me and him are in some weird kind of bond from today on, and he doesn't know it, and I don't realize it, hell, i don't even know his name because his parents haven't decided yet, but maybe one day he will cure cancer, or be the president of the united states, or abolish commercials, or legalize nudism, or something important like that, and I wouldn't know it because I wouldn't recognize him, but I can say I was there where it all started, when baby beat a turd and came into this world.

A Visa to freedom

Dr. Noah won the lottery and wanted to go to America.
Seemingly this should not pose much of a challenge, especially post-lottery-winning. However, he faced some difficulty.
"Try again in 2 years", the guy in the governmental office told him, and Noah thought he actually got lucky - some people wait for years before they are allowed to go to America.
And he knew what he had to do now.
As an expert in minimally invasive surgeries, one of only a handful in his home country, he knew exactly what the government now expects him to do, and indeed, he worked harder. He worked hardest. He worked hardestest. He hardly saw his wife and son, as he worked 8, 10 12, 20, 30, 50 , 50 , 80533452 hours a day, a week, a month. And they loved him at the hospital, he was the best minimally invasivologist in town, and even doctors from out of town came to see the him at work.

But after two years he got a letter from the government. It congratulated him for his fine work and was cordially informed that he was so good, they want to keep him. He can, if he wants, go to Venezuela and be a part of a doctors program. If he works hard enough, after 4 years he will get 10000 dollars. After he comes back home, of course.

Realizing this is not really going the way he wanted, he decided to make a run for it. Well, that is hard to do when you are on an island, which is exactly why Hector, his buddy's friend, who is a very talented carpenter, came in handy. Hector used to built ships from the time his father would sail into the ocean to catch fish and lobsters. When Noah told him he wants a ship he agreed, but on one condition - "I come too". I guess if you are about to cross an ocean, it might be nicer if there was a doctor on board, and Noah thought to himself that a ship builder most probably also knows how to handle ships, and though he was very wrong, he didn't know it yet.

So the ship was built, and they all hopped on board. it was actually more secret than that. Hardly anyone knew about the plans. Noah's mother wept quietly. It was so quiet that the air molecules weren't sure if they should vibrate or not, which is exactly why Noah himself always thought he is hearing his mom crying. Even now, when he tells me this story. He hears her mostly at night, even though she is thousands of miles away.

A GPS is a useful tool when you are about to embark on a sailing mission to a far away destination with a carpenter as your captain. Two problems persisted, though: 1. you just can't get a naval GPS on Noah's island. 2. The captain is the one making the decisions anyway and, being the happy, carefree person that he was, he decided a GPS is not really necessary. With Noah trying to convince him, because he was genuinely fearing for his life, Hector made a compromise - "we sail to Cayman islands and we buy there. And", he added, "that is where we will have our first breakfast".
It's been 5 years from that journey, and Noah hasn't been to the Cayman islands yet. Maybe one day, on his way back home from America he will go back there, just to check out what he might have missed.

They made their way to America eventaully, overcoming stormy weathers and ridiculously high waves. Noah lost 20 pounds, but he probably needed it anyway. There were lots of fish to catch, but no Einstein thought of bringing a fishing rod, or anything like that. I am thinking about those fish right now and I know they are fresh and delicious. They ended up on the coast of some south American country, which I can't remember right now, and somehow found their way to the promised land.

Noah told me this story while sitting on a bench during a 5 minute break we had between patients. We were interrupted a few times by the nurses who came to update us on this or that patient's condition. He looks tired and over worked, like the rest of us. he is in his first year of residency, like myself, but in a different field. It is much different than his lifestyle as a surgeon. as a senior surgeon. However, it's more practical for him right now.

I am looking at his tired eyes, and know that he is actually happy. ier. he made it, he is here. He beat his government, and they did not break his spirit. Just a few things to take care of right now, like bringing his parents. They won't let them leave, and they won't let him, the traitor who escaped his country, to go back. He tried once to come back, when his grandfather was dying. He knew he didn't have a chance, but owed it to him to give it a shot. "We are unable to approve your request" was laconically written on a sheet of paper that was sent to him in an ugly little envelope, and that was it. His grandfather is now watching from above, as his grandson broke the watery wall and made it into freedom.

He just misses those damn cigars.

The little dictator

Whenever I see Dr. J I think about Benito Mussolini. I can't quite explain it, but lately it has become a reflex of almost Pavlovian proportions - See figure walking down hall -> Recognize figure as Dr. J -> Think about Mussolini with dancing bundles of wheat around him.

"Why wasn't this patient extubated?", he would typically ask me, typically very early in the morning. If you don't know what "extubated" means, it actually doesn't matter, you can put any word there instead, like "violated with sunflower seeds" or "dressed like the little mermaid". It's the thought that counts, you see.

"I don't know, I just got here".
"Don't talk to me like that! I want to know who extubated her right now".
"Ok, who should I ask?", I turn my head for a second to get the patient's chart and grab the phone, but he already moved on to the nurse on bed 15 demanding to know why the patient had his urine bag on the right side of the bed, while he specifically demanded the bag be put on the left side of it.

He is a funny little guy. 5"5 with an extra inch from the shoes, it definitely has something to do with it. A little goat beard decorates his chin, and a noticeable-despite-all-efforts east European accent comes out of his mouth, which sometimes makes his temper tantrums funnier. He is a resident in his second year, which means he is actually not that high up in the food chain, and a food chain it is, but that is a story in itself.

I sometimes wonder about this guy. He mainly looks very lonely. I imagine him dreaming at night of little bundles of wheat, not too tall, doing all sorts of tricks at his command. Man, the intoxication of power. I wish I had dancing bundles of wheat at my command. I could do wonders. What will become of him in a few days, when he will no longer be able to order me around? He was clearly born to lead people, even if it is all the way to the river Styx.