Tracy's Travels

Safari in Yala National Park & Turtle Conservation Project

2012-02-04T12:51:00.001-05:00

Yala is quite a long drive from Galle as it rests on the southeastern coast of the island. There are closer national parks we could have ventured to with a heap of elephants and water buffalo, but Yala is the home of Sri Lanka's 200 leopards and in the off chance we could get to see one, we thought it was worth it.

An albino Green Turtle.
He likes me cause we're both pasty.

On our way to Yala, we made a stop at a Turtle Conservation Center and Hatchery. There are 8 different types of sea turtles, 5 of which can be found in Sri Lanka: the green turtle, Olive Ridley, Leatherback, Hawksbill and Loggerhead. All 5 species are listed as critically endangered or endangered. Despite this status, many people are illegally poaching turtle eggs when the turtles come ashore to nest on the beaches. People poach these eggs for human consumption or for sale to 'tourist attraction' hatcheries. The turtle's nesting grounds are also being destroyed by tourist beach development. Some hawksbill turtles are being hunted for the illegal tortoiseshell trade. At this point, for every 1000 turtle eggs laid, only one mature adult turtle is likely to survive. Awful.

Holding a Hawksbill turtle on the mend from a clash with a fishing boat.
His wounds are healing and soon he can return to the sea.

We made our way to a turtle conservation project along the southern coast to learn more. Here, we saw eggs that were ready to hatch any minute in the sand pit and the tiny baby turtles born in the past few days. The babies are kept for just a few days to get strong and then released back into the wild. The conservation center also had several wounded or sick turtles that were on the mend before they could be released back to the sea. One turtle had his leg cut off in a fishing trap and was here learning how to swim again with his new stump of a leg. The man running this place was very passionate about the turtles and was taking such good care of these little ones. It was great to see all the species of sea turtles in one location to really take in their differences. Very neat.

The sandbox of eggs!
Several species are about to hatch any minute now!

Hawksbill babies- just a few days old.
Growing big and strong for a few weeks to increase their
chance of survival before being released to the sea.

We hopped back on the road for a few more hours to reach Yala National Park. We met our guide in the nearby town of Tissamaharama, or Tissa for short. We happened to be on this trip on Poya Day (Full Moon Day), a major event for Buddhists. It's a big weekend of celebration and prayer in the Buddhist community and many families gather together for the day. There were many people taking in the holiday along the river in Tissa- boating and swimming around the lake. When we drove a little farther towards Yala, we saw groups of people bathing in the river- soaping up and rinsing off, changing behind the bushes, and getting ready to head to the temple for prayer. It felt very strange to watch these people bathing out in the open like this, but they don't have any other means of showering or cleaning themselves.

Bathing in the river.

The lake in Tissa.
A beautiful Poya Day to spend with nature.

Anyways, Tissa is where all the safaris take off from so you can see hoards of guides lining the roads trying to pick up tourists. Luckily, our resort staff helped set us up with the most perfect guide/driver. He was aggressive and knew how to track the animals so we could see everything we wanted to see. Any time we'd come up behind another vehicle, our driver would lay on his horn- like beep beep BEEEEEEEEP! He wouldn't let up until the truck in front would heed to let him pass. If they didn't, our driver would just begin to pass them anyways. We always won. Scary but fun. It allowed us to get up in front of the other safari trucks so we got first view of all animals.

Just after entering the gate, we were greeted with grazing water buffalo, wild boar, and land monitors. Land monitors are the largest lizard things I've ever seen! Apparently they don't attack humans, but they too closely resemble kimono dragons for my comfort. Not too long after we saw a large bull. He was grazing and playing in the brush just a few feet from our vehicle. He kept walking closer, seemingly unaware of our gawking stares and photo-snapping. So refreshing to see an elephant in the wild, roaming free of chains and stabbing spears. A beautiful sight.

Water buffalo and his best buddy
locked in a staring contest.

We continued down the road to see wild water buffalo and their bird friends. The buffalo and bird have a relationship of mutualism and when you see them together, they just look like ironic friends. Despite the large quantity of water buffalo we saw in Yala, the water buffalo is also an endangered species. Many times we would see the water buffalo hanging around the water holes and mud pits along with the spotted deer and antelope. There was one large rock formation that I joked reminded me of Pride Rock from the Lion King. I later learned it was called Elephant Rock- appropriate since it in fact looks like a side profile of an elephant.

We continued through the park to see all kinds of birds, bats (the largest bats EVER), peacocks, monkey and more! But the one thing I really wanted to see was a leopard. I told our guide to make that happen! He started to lecture me about how all tourists come to Yala and wanted to see a leopard and that there are just 35 leopards in this part of Yala. They're loners so they're spread out over the 3500 acres or something like that and blah blah blah.... I told him that even so I STILL wanted to see one! I gave a big grin so he knew I was being sarcastic (sort of) and he smiled back, turned back to the wheel and started driving around looking for something good to show us. Well, let me tell you, not 10 min later...... wait for it....... WE SAW A LEOPARD!!! It was pretty far back in the trees, sleeping away, but still, we caught a glimpse. And it's probably good to keep your distance from a leopard. That was all I needed to see to make my trip worth it!

Ok, so he's a little far away sitting up in the tree there,
but it's good to keep your distance from a leopard, right?

A little zoom action.

Standing where the Yala Bungalows were standing
before they were destroyed by the 2004 tsunami.

Our guide took us down to the shore where the Yala Beach Bungalows used to stand. They were completely leveled during the 2004 tsunami along with about 60 tourists and guides (40 of which were Japanese). Interestingly, not many animals were killed during the tsunami because they seemed to sense the impending danger. It has been reported that elephants screamed and ran for higher ground, dogs (domestic and wild) refused to go outdoors, flamingos abandoned their low-lying breeding areas, zoo animals rushed into their shelters and could not be enticed to come back out, and more... Based on those reports, it seems safe to assume that animals really do possess a 6th sense and were able to feel or hear the Earth's vibration and tipping them off to the approaching disaster. Thousands of lives were lost, but few animals succumbed to the tsunami. Fascinating.

A memorial for the 2004 tsunami.
Representing the 3 large waves that took out Yala.

We saw so much more than I expected and as the sun started to set, the safari became even more surreal. It was just gorgeous to see the sun setting over the water buffalo and crocodiles and elephants.... words can't even describe how incredible this experience was. Molly has been on a safari in Africa and she kept saying that it so reminded her of her experience there. I'll have to check that one out myself when I make it to Africa. But for now, I'll remember this trip and all it's beauty. Enjoy some more animal pics below!

So close to the animals!
A large bull grazing.

Love my monkeys!

Mama and baby!
Baby was playing with the bird- chasing with her trunk.

Eagle

Land monitor- doesn't it look like a kimono dragon?

Labor and Delivery at Mahamodara Hospital

2012-02-04T12:51:00.000-05:00

The last rotation week in ob/gyn found me at Mahamodara Hospital, just off the coastal highway linking Galle to Colombo. The hospital itself was heavily damaged by the 2004 tsunami, leaving large parts of the facility abandoned. Though many died in the initial wave, the patients of the Mahamodara were evacuated just in time to escape the tsunami’s second, more powerful wave. Although the mothers and children survived, the hospital didn’t. The venerable Mahamodara had been Galle’s maternity hospital since the 1940s. Now that it was gone, mothers were forced to go to the Karapitiya Teaching Hospital, which quickly became overwhelmed and overcrowded. On the first anniversary of the tsunami, workers broke ground on the new inland hospital and quickly set to work laying the foundation of what the Germans promised would be a state-of-the-art hospital for the people of Galle. But now, more than 7 years later, a concrete slab is all that exists of the promised maternity hospital. Thanks to the mismanagement of the donated funds, miscommunication, and cost overruns, the project came to a crashing halt. Enormous cranes and construction equipment can still be seen at the construction site, but no work has taken place for several years. Thankfully, attention was returned back to Mahamodara where several new wards have been built in the past few years, equipment has been donated and the Sri Lankan and German Rotary Clubs have made sizable monetary donations to revamp the women's hospital.

Most of our time was spent on the labor ward, where a dozen or so women on nearly bare cots with zero privacy would deliver the most beautiful little babies. Very different from my experience on L&D in the states.

Differences:
-no epidurals here! not even an option!
-nearly every woman delivering her first child vaginally will have an episiotomy (OUCH!). The professors are trying to reduce the number of episiotomies, however this number is still rather high.
-women are smaller here (smaller body and smaller pelvis) so many tear during delivery
-no husbands or family members allowed on the ward during delivery (b/c it's one large room with women laboring/delivering, and many women having their lacerations repaired --legs in stirrups with med students stitching).... though this is different at private hospitals where patients can have a husband or family member in the room
-no peds team on standby in the room
-C-sections are reserved for emergency, not elective (unless in the private sector)
-breech deliveries are still delivered vaginally, as are twins (most of these would be C/S in the US)
-patients hold their own legs and no one is coaching them through their pushing or telling them how long to push

Similarities:
-women are screaming out their labor pains
-oxytocin is everywhere!
-the little nuggets are so cute!!!
-both labor and delivery experiences make me scared to own a uterus

Ambulance carrying a new mom and her newborn from the delivery ward at
Mahamodara Hospital across the street to the newborn nursery and clinics.

Maternal mortality, however, is impressively low in Sri Lanka (39/100,000 – the lowest in the Asian region), no doubt thanks to the public health system. All women receive free care with regular visits at the community medicine antenatal clinics, with 99% having at least 1 prenatal visit during their pregnancy. (See my blog about the MCH clinic in Gintota for more on the antenatal screening and Public Health Midwives.) If there is any problem or concern the women are referred to Mahamodara for further investigations.

A heap of medical students watching a twin breech delivery.
There aren't normally this many students watching a delivery,
but with the unique nature of this birth, everyone wanted to learn.

Side note:

Dr. Fernando in Community Medicine had told me a story of one of her patients she referred to Mahamodara from an antenatal appointment- a pregnant woman came to see her at the MCH clinic for her 36 week check up. The woman was so large from swelling, she could barely open her eyes or stand on her feet. Her bare feet were so blistered and swollen, they appeared like a large driver head of a golf club. She couldn't afford a tuk tuk nor did she have any mode of transportation. She had walked the 5 miles to the clinic, barefoot and 36 weeks pregnant. Without having to do any investigation (though she did) she knew there was a problem. Dr. Fernando pulled out some money and got her a tuk tuk to send her immediately to Mahamodara Hospital. A week later, a skinny woman with a newborn came to the MCH clinic to see Dr. Fernando. She had no idea this was the same patient she had sent off in a tuk tuk just one week prior. When the woman arrived at Mahamodara, she was immediately taken back to the operating theater where she delivered her struggling baby at 36 weeks. Mom and baby were so happy and healthy, thanks to Dr. Fernando.

Adam's Peak

2012-02-03T13:38:00.000-05:00

Adam's Peak
known locally as Sri Pada

Adam's Peak is both an object of worship and pilgrimage for centuries for Hindus, Muslims, Buddhists and Christians alike. At the summit there is a huge boulder, about 8 ft high with strange impression on the bare rock that is claimed to be a footprint (Sri Pada) made by Buddha himself during the third of his three legendary visits to the island. The Christians believe that Adam, the father of the human race, was expelled from the Garden of Eden (Paradise) for eating the forbidden fruit and then cast back to earth, on top of this mountain where he stood on one foot for 1000 years to expiate his sin against the Creator. The Muslims have a similar belief to the Christians. They believe that the sepulcher of Adam lies atop the mountain. The Hindus believe that the footprint is that of Lord Siva, the 3rd god of the Holy Triad. What's really impressive to me is not the footprint itself, but the fact that this sacred place coveted by so many faiths is not wrapped up in a religious battle or turf war like those you find in places like Jerusalem.

The mountain itself is dramatic in that it rises abruptly from the lower valley with no other peaks around. It's not the highest mountain on the island, but it does offer an unobstructed view over the land and sea. We wanted to make our way to the summit before sunset to witness a unique phenomenon known as the irasevaya or "Shadow of the Peak". The rising sun casts a perfectly triangular shadow of the peak's summit, which hangs miraculously suspended in the air for about 20 minutes. The phenomenon has yet to be fully explained, thus the Buddhist take this as proof of Sri Pada's importance and supernatural quality.

Scared for my life and holding on to the seat in front
of me. I mean, you can see my hair is even flying up..
that's how much we were bouncing around in the car!

So off we go to make our own pilgrimage up Adam's Peak. The drive to Dalhousie, base of Adam's Peak was another terrifying drive despite the beauty of the tea plantations that surrounded us. The road was wide enough for one car and one motorcycle to fit side by side, but this was a 2-lane road apparently. Our driver, being aggressive as usual, was speeding around blind curves and honking to pass cars the entire way. The roads were full of potholes and rough edges, many of the edges dropped straight down the mountain side leaving no room for error. I was so nauseous and car sick- I came really close to throwing up and even had to open the window when I thought I was going to lose it. You know the road / drive is bad when Mollie can't sleep. That girl can sleep in any vehicle! But not this time... Holly and I both took a meclazine for the drive home.

Tea plantations everywhere. The scenery was beautiful.
Too bad we were too scared to enjoy it.

We finally got to our little hotel- Wathsala Inn, at the base of Adam's Peak. We watched the sunset over Adam's Peak from the patio and then after a delicious buffet with many new curries we attempted to get a few hours of sleep in before we got up at 2am to start our adventure. No such luck. Not only is it impossible for me to go to bed at 9pm, but buses were pulling up and tuk tuks were honking all night. The Russians in our hotel were celebrating someones birthday and of course were drinking heavily. They were so loud it sounded like they were in our room. I think I managed to fall asleep at 1:30am and then the alarm went off at 2. Sigh.

2:30 am. Here we go.

Sinhalese, Tamil, English

We were on the road at 2:30 am, walking from our hotel to the base. You can't tell where the trail really begins because it is lined with food shops, souvenir stands, and lots of folks selling warm clothing. We specifically chose to go this weekend instead of last because last weekend was Poya Day, or full moon. Poya Day is sacred for the Buddhists (80% of Sri Lanka) and many make the pilgrimage up to the top to give their worship to Adam's footprint. All 12 Poya Days are public holidays so travel around the island is also greatly increased with people celebrating with family. Needless to say, we wanted to avoid more vehicles on the road and more crowding at a tourist attraction.

We hiked the from the base of Dalhousie on the northern side of the mountain. Over 5,000 stairs and 7437 feet of elevation the climb didn't take us nearly as long as we had anticipated, BUT, as we approached the top, we started to drastically slow down until we came to a halt. We were stuck in a cue of people. We were about 100m from the top and moving about 1 step per 10-15 min. It was only 4:30 in the morning and people were coming down the other side so we figured we still had 1.5-2 hours to go less than 100m. Wrong. Mollie and I only got about 50m from the top by 6am. The sun began to rise. We didn't move a single step. Luckily, we were stuck at a point on the east side of the mountain with a clear view of the valley and sun rise. It was spectacular. Such bright reds and oranges cast by the sun and a bright moon overhead lighting the mist over the reservoir at the base of the valley. You could see miles out and the mist continued to clear, the clouds lifted to form cotton balls around a lower segment of the mountain. What a gorgeous site to see. My pictures just don't do it justice.

So close to the top but not moving.

I began to have some hope again as I started to see a stream of people starting their descent, however, our line continued to stand still. It was frustrating to see all the punk teenagers jumping the rails to go up the "down" side. These people were getting to the top while the rest of us were standing still. If they wouldn't have all cut the line, our line would actually move. I sound so old. But it was frustrating and disrespectful. We were so close, but the top was so jammed up with people going up through the exits (there are 3 trails on different sides of the mountain that lead to the top) and to top it off, Adam's foot print was closed off so we wouldn't be able to see it anyways. All in all, we stood stationary 50m from the top for 2.5 hours. TWO AND A HALF HOURS! We had met a nice British couple on their honeymoon in line behind us and we were all able to keep ourselves entertained, but when we spoke with a European couple on their way down who told us it wasn't worth it, we decided to give in and start heading down to find Holly. We were freezing and frustrated. We also knew that Holly hadn't packed as many warm clothes as we had so if we were cold, she had to be freezing. Enough was enough.

We found Holly on our way down. She was also stuck in the line and ended up with a group of French tourists so she got a chance to practice her French! Since she had packed fewer warm clothes, she was freezing and hoping we'd come down soon.

The way down is always worse than the way up. Some stairs were wide, some skinny, some narrow, some high, some short, you get the point! The hike was much more beautiful on the way up- in the dark. It was actually very sad to see just how poorly the Sri Lankan people, particularly the youth, treat this supposedly sacred trail. People were peeing in the bushes despite having toilets every hundred meters. We watched locals- both old and young- throwing their trash anywhere they pleased. The bushes, the stairs, everywhere! Guess the concept of "leave no trace" hasn't made it's way here. They are also burning their trash along the trail- plastic and all. Really makes for some good air quality when sucking wind on your way up!

Coming down with the clear blue skies
and the moon above.

Down, down, down we go.

It was really quite sad that the foreigners treat Adam's Peak with more respect than the locals who cherish Sri Pada as a sacred pilgrimage.

Climbing Adam's Peak was a great experience and a gorgeous sun rise, but next time I'd avoid the harassment by adolescents with all their pushing and shoving, avoid the line and overall trashed staircase, and opt instead to climb Sigiryia. After all, Adam's Peak is only the 4th tallest mountain in Sri Lanka so it's nothing to brag about :-)

Unawatuna

2012-02-03T11:22:00.001-05:00

Before the tsunami of 2004, Unawatuna was named one of the best 12 beaches in the world. The tsunami swept away most of the restaurants and businesses and destroyed the coral reef that made this spot so rich in biodiversity and enticing for snorkelers. Despite the lack of response from the government, the people of Galle worked very hard to preserve what was left of their businesses and begin the rebuilding process. It is rumored that celebrities like George Clooney and friends donated a lot of money to help rebuild this beloved beach. I don't blame them for wanting to get this place back up and running! Just 7 years after the tsunami and this place is as gorgeous as ever. The beach is lined with cute bungalows, bars, restaurants and small mom & pop guesthouses. The food is delicious and the views are fantastic.

With this beach being a mere 3 miles away, it's no wonder Unawatuna became our go-to beach when we'd get out of the hospital early and want to play the huge waves or eat dinner with the sunset and ocean crashing. Plus, it was the only spot we could find a pizza. And sometimes, you just need pizza.

Fireworks over Luck Tuna

One of our favorite little bars, Lucky Tuna, was right in the center of the beach front. We were introduced to this place on New Year's Eve when our tuk tuk driver, Dinesh, brought us here. Dinesh is born and raised in Unawatuna so he knew every guesthouse and restaurant owner and all the workers along the beach. Dinesh got us drinks all night and stayed with us during the New Year celebration, watching over Holly and I like our very own body guard. He was very protective of us and if any guys would start to bother us, he would come over and rescue us. He definitely made us feel safe in this foreign land. The nice thing about Lucky Tuna was that it was a locals joint, but many tourists also hung out here, making this place a great mix of people to talk to. AND then the British Royal Navy decided to make this their go-to bar.... so we highly enjoyed that.

One of the many gorgeous sunsets at Unawatuna.

One evening, while waiting for Dinesh to come pick me up, I met a woman who owned one of the restaurants on the strip. It was the week we were on our Pediatrics rotation working with Dr. Jayantha. Apparently, her daughter was saved by Dr. Jayantha 22 years ago and she has loved him and prayed for him ever since. She told me she owes her life and happiness to him. She was so excited that we were learning from him, she asked me to invite the other girls back with me to experience some 'true' Sri Lankan curry at her restaurant. We took her up on this offer and had some of the most amazing curry with real spice! Not the 'tourist' level of spice, but the real deal. It was delish! We also met her husband, Anil, a jeweler whose work we had been admiring through the window for weeks. After meeting him, we ventured into his store... bad idea! He has some amazing work and such beautiful and rare gems. All three of us ended up making some purchases with gems unique to Sri Lanka. The one I really fell in love with was the star ruby. It's gorgeous! And ridiculously expensive- go figure. One day, I'll make enough money to get a ring or pendant made with a beautiful star ruby.

The gem I finally decided on for my ring.
Rhoti (don't know how to spell that)-
a type of quartz unique to Sri Lanka.

Ayeurvedic medicine at the Spice & Herb Garden

2012-02-03T10:11:00.001-05:00

En route to Adam's Peak our driver made an unexpected stop at a Spice & Herb Garden. We got a tour around the gardens to see all the different types of herbs and spices used in Ayeurvedic medicine. I never knew how vanilla and pepper grew on vines and I've never seen the cinnamon bark on the tree. Very cool.

We learned about different concoctions of coconut oil, cinnamon, ginger, sandlewood, jack fruit and many more. Our guide was a young man who was in his last year of university, studying ayeurveda. He was quite knowledgeable and after discovering we all worked in medicine as well, he decided to give us demos of everything.

Since I am covered in mosquito bites from head to toe --seriously, there is not a spot left on my arms or legs to bite-- he mixed together a waxy balm to rub all over to stop the itch and prevent more bites. I smelled like a citronella candle, but I didn't get any more bites that day.

Then he made an oil mixture of sandalwood oil and vitamin E for "anti-wrinkle" cream. I volunteered for that one (see my wrinkle story in the Surgery post). He ended up giving me a rather long face massage with this oil! It was incredible. Then came the headache relief- another menthol-smelling wax that he rubbed/massaged into my temples. And since Holly was coughing, he made her a syrup mix of a whole lot of brown stuff that smelled real bad- Yuck!

Then came the best part-- green oil back, shoulder and leg massages! 45 minutes of free massage. This was better than most massages I've paid money for. I don't know if my wrinkles will disappear or Holly's cough was cured, but I think I like this ayeurvedic stuff!

Mirissa and Weligama

2012-02-02T19:05:00.001-05:00

We had so much fun on our bus adventure to Hikkaduwa yesterday, we decided to take the bus west to Weligama and Mirissa beaches. We were such pros this time around! We didn't even have to ask for help at the bus depot... luckily we got on the right bus. The best part of this bus ride was a man who got up front and started singing. I think he was singing for his bus fare, but he sounded like a cat stuck in a dishwasher as he paced up and down the aisle. Awful.

Fishing boat at Weligama.

Since we were on the express bus (though I'm pretty sure every bus in Sri Lanka is an express bus) we got to Weligama in just 45 minutes. Weligama is on the south coast and it's a cute little town without a whole lot of tourism, mostly a fishing town. But there is one standout of Weligama- Taprobane Island. On this small little island just off the shore, there is a red-roofed colonial villa that used to be owned by some Count and then an American novelist (can't remember who) and now you can rent out the entire villa for $1750 a night. You can walk out to the island at low tide, but come high tide, you're secluded on your own little land. Kinda neat! But other than that, there is not much to do in Weligama. We got off the bus here thinking we'd see some good little shops or restaurants, but nope. Just a whole lot of fishing boats anchored on shore, waiting for their turn to go back out. But they were pretty, so I took pictures.

Taprobane Island

So we headed back to the road to catch the bus a few more miles to Mirissa Beach. Mirissa is sleepy little beach town that hasn't been corrupted by pollution, extreme tourist traffic, or those awful people walking up and down the beach asking you to buy their junk. Hopefully this doesn't change now that word is getting out about the cheap whale watching excursions from here. Mirissa is laid-back and beautiful. Just what we needed on this Sunday.

Fresh catch for sale.
Squid, red snapper, butter fish, and I don't know what else.

We hung out in the sun, swam in the ocean and watched the fishermen set up their fresh catches along the shoreline. You could pick out your fish or prawn or crab, whatever, and have the restaurant cook it to your liking. Those were honestly the largest prawns I've ever seen! They don't call them jumbo for nothing! I actually thought they were lobster but I was corrected by the fisherman. I've never seen some of those fish and I'm really hoping none of them were swimming around me when I was in the water. Dinner time came and surprise surprise, I went for the curry! It was SO good and once again, so cheap. While watching the sun go down, we saw a group of cows wander onto the beach. I have no clue where they came from- cows are everywhere here- but they just walked on down to the water and hung out for about a half hour. Never seen that before!

Cows chillin on Mirissa Beach

Ginormous prawns and pretty colorful crab.

Overall a great day in Mirissa. I wish we had more time to spend at this peaceful little spot, but alas, we must head back to Galle for our OB/Gyn rotation!

Elderly home and Orphanages

2012-02-02T11:33:00.000-05:00

When I wasn’t in the operating theater this week, I was out in the community, learning more about the public health system, specifically the care of orphans and elderly. My colleagues and I have already been to a government run orphanage, and this week we wanted to see how the private non-profit orphanages compared. We visited an SOS Village, an Austrian run organization which hosts 12 children per home in 12 total homes on the property. Each “family” home consists of children aged 0-16 years brought in by the courts in cases of abuse or abandonment. The children are cared for by a “mother” in each home who cooks, cleans, and teaches the children valuable life lessons. Each“mother” has years of training and a very intensive screening and selection process. The children still attend public schools like their peers, and return to the village to live a life as close to their peers as possible. They are also set up with vocational and other job training when they age out of the program. It was wonderful to see an organization like this one, working so hard to give these children a rich and meaningful childhood.

Walking with a group of Community Medicine students around the SOS Village.

Two of the family homes at the SOS Children's Village in Galle.

Lots of beauty (and perfect for playing cricket) on the grounds here.

We also made our way to a catholic-run elderly home where I had the pleasure of meeting an amazing woman who was blinded by the tsunami. She told us her story and how the sisters had found her on the streets, nearly dead, and brought her to the facility because she had no money, no family and no way to survive. The sisters were able to find a surgeon, who just this past year, performed an incredible surgery to restore her vision! He was able to see for the first time since 2004.

There were so many great stories from the folks at the elderly home, but what I liked most about the facility was that every resident helped out in any way they could. Some set the dining room tables for meals, others cleared dishes, some peeled vegetables, and some knitted bedding or doilies for the sisters to sell for money for the home. Not everyone could pay, but no one was turned away.

With another fantastic week in the books, it’s hard to believe my time in Sri Lanka is coming to a close. I have learned so much in my short stay; it will be hard to leave. I am very grateful to have had this learning opportunity here in Sri Lanka and I hope that I may return here as a provider one day.

Hikkaduwa by government bus

2012-02-01T22:47:00.002-05:00

My view for the day.

Hikkaduwa Beach is another coastal town known for their surfing and cheap bungalows for tourists. North of Hikkaduwa is where you find many of the expensive Ayeurvedic Resorts and Medical Spas, along with pricier accommodations. Hikkaduwa is where someone like me stays :-) Plus, there's a night life in Hikkaduwa and cheap rotti stands with more delicious (and of course cheap) curry.

The unfortunate thing about Hikkaduwa is the uncontrolled development that has taken place here since the tsunami of 2004. There was so much regulation focused on the major coastal cities and expensive resort areas that places like Hikkaduwa built themselves with a sort of competition to get closest to the shore. Basically, the development has eaten into the beach and polluted the shore. Many of the small hotels or bungalows have built literally on top of the water and so they've had to place sandbags to help keep the surf out of their beach-front restaurants and to prevent the establishment from sinking with the beach erosion.

Even so, Hikkaduwa offers a lot of options for the low-budget traveler. There are abundant diving centers and certification courses, glass-bottomed boats that take you to the Coral Sanctuary for snorkeling as well as surfing schools for board rentals or beginning surf lessons. And of course, there are plenty of cheap eats, drinks and cabanas for the sun bathers.

Sunbathers and surfers.

To get to Hikkaduwa, Molly and I decided that we wanted to explore the public bus. Yes, that's right. We OPTED to take the bus. After being overpowered on the road by so many buses, we figured we'd be safer if we were the ones actually on the bus. Right?

To get to Hikkaduwa we had to take 2 different buses. One transfer. Simple. Well, we made the transfer all right, but getting on and off is a whole other story. Buses here don't actually stop to let people on or off. They slow to a roll. So we watched several people leap for their lives to get off at their stop, or at least near their stop. I was a bit nervous to jump from a moving bus for many safety reasons, however, I also had my hands full with my beach gear and a liter of water. I had no way to even hold on to the handles while stepping down the stairs to my exit. Lucky for us, the driver took pity on the suddahs (have I defined that term for you yet? I will in just a minute.). He slowed down to a full stop for us! I was very pleased and turned and yelled "Istuti!!!!" to him ("thank you" in Sinhalese) but the moment my feet were on the ground, he had already taken off.

Just your everyday Sri Lankan Naval
ship cruising by with their guns pointed
towards the beach. No. Big. Deal.

We took off towards the beach. Mollie and I found a set of lounge chairs in a cabana that had our name all over it. It was such a great spot to sit and watch the surf lessons going on. The weather was perfect. The breeze was great. The shade of our cabanas was nice when we were done with the direct sun. Everything on this beach was great... until we saw the boat with guns!!! We were both staring and I had to take pictures with my zoom to verify that we were in fact seeing guns on this boat. We were told that it was the Sri Lanka Navy. They patrol the beach. I couldn't help wondering what it is that happens on this beach that they need this type of heavy machinery to patrol a tourist beach. Hmmm. The boat moved on and we relaxed. The surfers continued until the sun set. We walked up and down the beach, people watching and checking out the small restaurants and bungalows.

WIth the sun setting, we decided to find ourselves a nice rotty stand for some dinner. We made our way to a little rotty shop and had another delicious rice and curry meal and a dessert rotty afterwards, all for less than $3 USD. Love it.

My rice and curry in Hikkaduwa. Less than $3 USD!

Rotty man! Forget the curry, he made me a
delish pineapple and chocolate rotty for dessert.

The bus ride home was a bit more challenging in the dark. Finding the bus stop in the first place was tricky. The stops are hard to see with just a marking on the road and so it took us a little ways of walking to find one. In the mean time tuk tuk drivers keep asking "where are you going madame? I take you." It gets really old having to repeatedly say no to tuk tuk drivers who won't stop harassing you to let them take you back. My argument was always, "If you can take me back to Galle for 50 rupees a piece, we'll get in. Otherwise we're taking the bus." The tuk tuk driver would say, "Ok, ok, 400." I would say, "no, 50 rupees each. That's 100 rupees or we're taking the bus." Usually they'd walk away when they realized I was serious about taking the bus. But one man did not give in. After repeating the same lines at least 4 times and him walking away, coming back, he looked at me and said, "Why can't you pay for tuk tuk? What are you? A beggar in your country?" I laughed and said, "close, I'm a grad student and I live off loans." I don't think that translated since he lives in a country where education, including graduate or medical school, is free. And there are no other tourists on the bus. All tourists are in tuk tuks. I was very confusing to this man. So we flagged down a bus.

Taking a bus in a foreign land is quite hilarious. You just have to laugh. You're going to a place you've never been. Have no idea what your stop actually looks like. Can't read most of the signs (if any) to determine where you're going. You can't talk to the bus driver to ask where to get off. It becomes a game of me trying to pronounce my destination and them trying to understand my improper pronunciation. In trying to get back home to Galle... I would say Galle (pronounced like Gall-stone). They would say ???? I would try again. Someone would say "Gall-lay" and I'd say "Gall?" then add "Fort" for good measure. Eventually, our name game would end with some local who would take pity on me and tell me when I needed to get off.

Fisherman stilt at Hikkaduwa.

At the Galle bus station, where we'd wait for Dinesh to pick us up in the tuk tuk, we'd always have random people come talk to us. People here are so friendly and they're so curious about foreigners, especially white people. It was strange at first, but then it was kind of nice because it would keep the harassing tuk tuk drivers away. This particular weekend, we ran into the same couple with their toddler at the bus station back to back nights. It was like they were waiting for us. They didn't have much to say. Just hello and where did we come from. Then they'd just stand there and stare at us. They wanted us to say hi to their baby and then wanted to just stand with us and be our friend until our ride came. It's quite the odd experience. It's like being a celebrity, but not for any reason in particular.

*Suddah= a Sri Lankan slang term with negative connotations, meaning white person. Furthermore, they call anyone a 'suddah' if you show up early or on-time for something. A meeting, a class, you name it, the Sri Lankans run late for everything!

Surgery at Karapitiya

2012-02-01T12:27:00.000-05:00

Finally! Surgery week!
Wooohoooooo!

Operating table. No fancy tilt motions here, just up and down.

In my third week at Karapitiya Hospital I was introduced to Dr. Kumara, senior lecturer in Surgery. Participating in various surgical cases was what I was most looking forward to on my rotation in Sri Lanka. The first thing out of Dr. Kumara’s mouth was, “You’re from the USA? You know Mrs. Obama?” I laughed and said, “No sir, I don’t.” He immediately moved on to his next line of questioning, asking why I chose Sri Lanka of all countries. I proceeded to explain my interest in global health and disaster relief. He cut me off and said, “But there’s no natural disaster right now.” A grin formed across his face and he continued, “Just our whole country’s a disaster!!!” With that introduction we were handed our scrubs and taken to the operating theater.

Changing into some damp scrubs in a small closet.
The white shoes on the floor are the required OT shoes
that we wear instead of booties over our own shoes.

Walking into the operating theater I noticed it was quite a different set up from the operating rooms back in the states. And it’s a good thing I had a surgical mask on to cover my mouth because my jaw definitely dropped! Patients were lined up right outside of the open theater doors with their medical chart in hand. Some patients were even curious enough to stand and watch the ongoing procedures from the doorway. On the other side of the patient bench was a make-shift PACU where the post-operative patients were still coming out of their anesthesia. Inside the operating theater, there were multiple procedures going on at the same time. In one corner of the room, a woman was having a lumpectomy under local anesthesia. In the center of the room, a man was under general anesthesia having an open cholecystectomy. Finally, off to the side of the room a woman was getting a carpal tunnel release.

You can see two of the operations going on in the room.
Far patient is lumpectomy, close patient is getting started
with general for an open cholecystectomy.

As I was taking in the similarities and differences of the operating rooms, one of the general surgeons asked me to scrub for a thyroidectomy. As I got ready to scrub, I noticed there were size 6 or 8 gloves. I’m a 6 ½ so my choices were too tight or too loose. Thankfully my hands managed with a size 6. Anyways, the case got underway and I was impressed by the speed and precision of the surgeon. Thyroidectomies are a very common procedure here in Sri Lanka and these surgeons perform so many each day, I'm sure they could do this procedure in their sleep. A short time later, we were done and ready for the next patient. The turnover time between cases is quite rapid. Turning over an OR at home takes a bit of time, but here, there is no time to waste. They have so many patients in need of surgery and not enough resources to do so.

One thing I found truly amazing about the Sri Lankans is their strength to overcome adversity. But more impressive is the way they do so without complaint. The patients waiting in the hallway of the theater could be there all day long, sometimes not having their surgery until 1 in the morning, but there was no complaining. I commented to one of the orthopaedic surgeons about how refreshing it was to have people be thankful for the help they are receiving instead of complaining about the wait time, or cosmesis, or post-op pain, or even the food at the hospital! The surgeon told me that Sri Lankas are very accepting of their own problems and illnesses. Then he smiled, leaned in and said, "Sri Lankans don't sue their physicians and that's something you all have to worry about over there." Sri Lankans understand that this is the life they were given and they will deal with it as best as they can. No ambulance chasing or frivolous lawsuits here! Must be nice...

Assisting on a thyroidectomy.
Notice how I'm the only one wearing a mask over both my nose and mouth?

After a few ortho surgeries, I stepped into the general surgery suite to watch an open cholecystectomy. Since we do these procedures laparoscopically, it was a new operation to me. There is only one scope for the entire hospital so most all procedures that we would do laparoscopically at home are performed as an open procedure here.

Similarly, the hospital does not have mesh implants for hernia repairs. Instead, I learned an old suturing technique to weave a meshwork of suture over the opening. Quite impressive and cost effective. As a global practitioner, I’ll need to be prepared to assist in surgeries with fewer resources and embrace both old and new techniques to achieve good end results. I am very grateful to have watched so many procedures and techniques that I won’t get to see (or rarely see) in my training in the US.

I also spent time with Dr. Kumara during his thyroid, vascular, and endoscopic clinics. In the thyroid and vascular clinics I was surprised to see patients bring their own injections to Dr. Kumara. I have been in peripheral vascular clinics and seen the sclerosing process, but I had never seen a steroid injection delivered right into a goiter. Once again, these Sri Lankans showed impressive strength and not one of them flinched or grimaced at the needle in their throat. I’m pretty sure I would have cried. In the endoscopy clinic, I was was stunned to see that patients were not sedated for upper endoscopies or colonoscopies! But once again, there are no resources available to take care of these patients post-procedure if they were to have an anesthetic. So using a local anesthetic gel on the probe is the only feasible option. Again, not sure I would have been so brave.

I'm not sure I want to share this next story, but since I'm putting it all out there, I may as well. In the middle of the thyroid clinic, Dr. Kumara looked up at me and shouted, "You're going to live to be a hundred!!!" He was so excited I had to laugh and ask why he knew that. Without hesitation he told me it's because I have 5 wrinkles. Great. Awesome. Fantastic. I'm an old hag. I told him that I was trying to get rid of those!!! He shouted "NO! Keep them! You must keep them!" He was serious. And I'm not sure I have a choice in the matter, so I guess I'm keeping my 5 wrinkles, which apparently count for 20 years a piece and I'm destined to live to 100. Longevity does run in my family. I guess I can't take offense to this comment because just moments before he had guessed that I was 23 or 24 years old. Close Dr. K, close. After note to this story- I bought a Sandalwood Oil thingy from an Ayeurvedic herb garden that we went to that next weekend. Apparently mixing sandalwood oil with Vitamin E or aloe and putting it on your face 2x week will get rid of wrinkles (or cellulite or scars, etc). Yep, it scarred me.

This was the wrinkle day. Can you see the 5 in this close up?

Back to western medicine. When we completed clinic, Dr. Kumara looked at my colleagues and I and said, “WWII is over, you can go talk to the Germans now!” Funny man. Loved him. We got along splendidly. So with that proclamation, we headed to another operating theater where they were having casualty day and met up with two German medical students, also doing an elective rotation. We spent the rest of our day in the casualty theater assisting in I&D’s, suturing small lacerations and bandaging head wounds. Overall, surgery in Sri Lanka very much surprised me. For the limited resources available, the shortage of qualified surgeons and the ever increasing number of patients in need of surgery, the surgeons here are very efficient with their time, skilled in technique and resourceful. We may have different ways of carrying out a procedure, but we all get the job done.

Open cholecystectomy

Looking into the "sterile core" on the left. Sutures, gloves (size 6 or 8 only), other random things you may need during surgery straight ahead.

A trip to the orphanage

2012-01-31T12:13:00.000-05:00

An interesting adventure we had during our pediatric week was a trip to a government run orphanage. This was a very bizzare, sad and awkward experience. It was bizzare because we were under the impression we were going there to do well child checks or immunizations, but instead, a consultant dropped us off and told us he'd be back for us in an hour. The 3 of us just looked at each other puzzled. What were we supposed to do?

A woman took us into the kid's room- one large room lined with row after row of cribs of crying infants and toddlers. We saw 2-week old infants up to a 15 year old with cerebral palsy. This poor child had not had any physical therapy or treatment for his CP and his extremities were so far deformed, he was no longer able to sit in a wheelchair or lay flat on a bed. When we saw the 3-4 year old's room, all the children were napping. I was surprised to see not one, but 2 children sleeping on each bed. There weren't enough beds for each child. There were no guard rails on these raised beds. Surprisingly, there was a HUGE play area that was donated by some Germans. This play area had thousands of balls and tunnels and areas to climb. It must have been 20 feet tall and put any McDonalds play area to shame. I guess this is where all the money is spent. Most children are under the age of 4 here and many are lucky enough to get adopted by Sri Lankans or foreigners (mostly German as we learned).

It was sad because many of the kids were crying or sick and had no one to care for them or console them. Many of the children here are a product of rape, or born to a young girl unable to afford a baby, abandoned at the hospital for no reason at all. One toddler had only been at the orphanage for 3 days. His mother couldn't afford to keep him and after 14 months, brought him to the orphanage. The child hadn't stopped crying since he arrived. I almost cried with him when I heard his story.

The awkward moment came when the lady asked if we saw any we liked and wanted to take home with us. Uhhhhh... I suddenly felt like I was shopping for a puppy in the mall. It was terrible. Just walking around, looking in each crib, giving hand shakes and playing peek-a-boo type games with the ones that could stand and grip the edge of their crib. It was awful. We didn't know what else to do. We weren't allowed to take them out of their cribs or go play with them or feed them or really assist in any way. I wish we could have helped out. With feeding, with bathing, play time, teaching, I don't know, but something...

We didn't know what else to do. We went into the office and chatted with the woman about the set up of the orphanage and how the government is structured to take the children and feed and educate them. Again she asked us if we liked any. It was sad to leave those kids there, and I'm ashamed to admit it, but I was somewhat relieved when our ride came back for us. I needed the sales pitch to end. I wanted to help, but I wasn't there to shop and buy and that's how these women made me feel. I truly wish there was more I could do for these kids.

Maternal Child Health Clinics

2012-01-31T11:50:00.000-05:00

Since Sri Lanka is a public health system, it was really important for me to see how the clinics are run in the community. We were lucky enough to go to 2 different Maternal Child Health clinics (MCH clinic). Each MCH is run by the Medical Health Officer (and Public Health Midwives if it's an antenatal clinic). The first MCH clinic was a Muslim clinic where we saw antenatal checks and child immunizations. The child vaccination rate is up to 98% here in Sri Lanka. Impressive! No one over here is claiming autism or other ridiculous reasons for not vaccinating their children. They've eradicated polio (despite having India as their neighbor) and several other serious illnesses thanks to their vaccination programming and ease of the MCH vaccination clinics.

In addition to the child vaccination clinics, we were able to go to an MCH clinic in Gintota, outside of Galle, to observe an antenatal day. Here, the Public Health Midwives run the show with an OBG consultant either on call or present at the clinic. The Public Health Midwives are trained much like our Nurse Midwives, though they rarely do deliveries outside the hospital unless the mother cannot make it to the hospital in time. Sri Lanka has a 96% institutional delivery rate, a vast improvement thanks to several government educational outreaches. With the increased hospital deliveries has also come a drastically decreased maternal mortality rate. In basic language: Sri Lankan women are now being educated on prenatal and postnatal care and getting themselves to a hospital for a safer delivery.

MCH Clinic in Gintota
Antenatal clinic day

Paperwork with measurements, education checklist, vaccinations and other checkpoints for all pregnant mothers. Completed by the Public Health Midwife. The PHM and patient each keep a copy and have to bring to each visit.

Patients entering the clinic and waiting to register.

After registration, a nurse documents their vitals.

At the MCH appointments, the midwives are responsible for tracking fetal heart tones and measuring the fetus' growth. There are no dopplers or ultrasounds however, so they use a pinnar (like an ear trumpet). This plastic funnel looking instrument is pressed into the mother's abdomen after performing Leopold's for the fetal positioning and finding the shoulder. I had a really hard time hearing the fetal heart rate (which sounds the same as through a doppler), but after a few tried, I was able to properly line up my ear canal with the open tube of the pinnar and hear the sounds! Success! We are so reliant on technology in the US it's sad. What a simple and low-cost way of hearing the fetal heart tones. I'm glad I was able to acquire this skill.

Patients lined up outside the exam room.
Waiting to be seen by the Midwife.

Public Health Midwife measuring the fundal height.

Public Health Midwife using a pinar to hear the fetal heart tone.

Pediatrics at Karapitiya Hospital

2012-01-30T11:29:00.004-05:00

In our second week at Karapitiya Hospital we were able to do inpatient pediatric medicine. The pediatrics (peds) ward is a much different experience than our adult medicine week. Here, there are several consultants that round on the ward, so the medical students and house officers are divided up into much smaller groups. For me, this was such a great experience because I got to round with Professor (Dr.) Jayantha who LOVES to teach. He was so wonderful in making us feel included as learners, spoke only in English- except to the patients of course- and PIMP'ed us just as hard (if not more so) as his students. For my non-medicine followers, PIMP stands for 'put in my place' and it's a method of teaching where the teacher (in this case Consultant) asks the student questions one after another basically until you feel like a total moron and can't answer any more or they're satisfied with your responses. Then you have to go look up whatever you didn't know and report back. Anyways, I learned so much from my few days on the peds ward- I'm getting better at reading chest x-rays, deducing what type of bacteria may be to blame based on physical exam and radiography, and how to do a proper neuro exam on a patient with cerebral palsy.

From left: Senior Registrar, Mollie, Me,
Professor (Consultant) Amarasena, Holly

One day we did rounds with Professor Amarasena who is also a fantastic and enthusiastic consultant and teacher. During rounds he asked me to inspect a child and examine him. All I knew about the child was he was there for a broken arm. It seemed strange that a child was admitted for that, so I figured something else was up. Dr. Amarasena specifically asked me to inspect and palpate the child's head. When I did so, I noticed that this 2+ year old child still had an open fontanelle. This should have been closed by now, so there was clearly something besides a broken bone going on. Prof Amarasena looked at all of us students and told us to write down 3 differential diagnoses for this patient. He then looked over at the 3 of us sweaty monsters dripping in our white coats and said, "You too. Write down 3 diagnoses and then we go snowboarding!" Huh? Holly and I looked at each other and our eyes both said 'did he just say snowboarding'? He laughed and said, "yes, we go snowboarding." Holly replied with "I'm good with that!" We were a little embarrassed that we were sweating so much. How is it that none of these people were sweating? They never sweat! They never drink water; they never pee; they never sweat! How is this possible? Anyways, we got back to inspecting the child for our differentials. I then noticed that the child had blue sclera (or maybe I was making myself see blue sclera because I had a pretty good idea what this kid had) and immediately my differential included osteogenesis imperfecta (OI). Luckily, I had done research on OI when I worked at Children's Hospital in Boston so when he started to pimp us on OI I was able to answer all his questions.

Pediatric Ward

The hallway outside of the busy renal clinic.
The waiting room was stuffed full.

One disorder that I noticed commonly on the peds ward was nephrotic syndrome. This is much less common in the States and it was a great opportunity for me to learn something new. Professor Jayantha brought us to his renal clinic where we saw many babies and young children with pyelonephritis, UTI's and nephrotic syndrome relapses. The clinics here are jam packed with people lining up and down the hall due to an overstuffed waiting room. Once the patient's name is called, they are brought to our room. A basic exam room with no bed, no supplies, just a typical-sized doctor's office room with a dining table and chairs. There are 3 physicians seated at the table with 3 chairs by their side, ready to be filled by 3 patients. There are also 7 or so of us students and 2 nurses in the room....nice and cozy huh? I've been slowly getting accustomed to the heat and humidity of Sri Lanka, but wearing my heavy white coat and standing still in a room this crowded without circulation....this was the closest I had come to passing out during my training. I was literally touching shoulders with both Mollie and Holly and my back against the wall and half a foot away from the patient sitting in front of me. But, aside from the gray-screen that started appearing in front of my eyes, I did learn a lot about nephrotic syndrome and the various types- something I had know nothing about before. Prof Jayantha is very passionate about this subject as it is also his area of focus for his research. I'm not sure if it's Prof Jayantha's teaching or what, but I might consider pediatrics after all....

Saying that out loud (or writing it to you all) makes me laugh. It makes me think about how scared I was of doing well child checks during my primary care rotation. It seemed like such a big job to make sure you remember all the important educational points to discuss with the parents and to do an exam on a kid without making them cry, well that's a skill I didn't think I had in me. After doing my first few pediatric appointments and well child checks, my preceptor, John Sallstrom, asked me if I was sure that I didn't want to go into peds. Flattered, I laughed and said, no. But John, you may have been on to something!!! I think I'm digging this pediatric thing after all. Guess this is why we do rotations in every major area before we apply for jobs!

Pinnwalla Elephant Orphanage

2012-01-30T10:29:00.003-05:00

We took off from Madawadamulla this morning before sunrise, though we knew the sun would be rising any minute since the steady chanting from the Buddhist temple had begun. Even at this early hour we had to dodge stray dogs, cattle, goats, and birds in addition to the motorbikes, bicycles, buses and tuk tuks. Pretty sure my driver was preparing for a NASCAR race with the way we were speeding around the windy mountain roads of the Hill Country. Passing vehicles around blind curves, our driver slammed on his brakes so often I thought my breakfast was going to come up. There were several very close calls where we were within inches of losing our lives- I know this because I saw my life flash before my eyes about 6 times.

When we arrived in Pinnwalla, it was clear that the town's entire economy revolved around the elephants and tourism. There were beggars waiting next to our minivan ready to harass us. I looked down the road to where the elephants were bathing in the river and saw a row of tourist shops selling souvenirs and knick knacks. "Madame, which kind of magnet do you like? Please come in my shop. Have a look." My favorite lady was selling "handmade" hobo bags with elephant print fabric---ironically identical to the ones I saw all over beach towns in Thailand. Maybe she hand made all of those too... I could tell this wasn't going to be the "orphanage" that was described in the travel books where they talked about rescuing the wounded and orphaned elephants from the civil wars. Further describing how many of these elephants had a leg blown off from stepping on landmines.

Well, I saw no three legged elephants and the only injuries I noted were from the chaffing of the metal chain the elephants wore around their ankle. These elephants were on house arrest. It was heartbreaking. This place was a sham and they should really reconsider naming the place an elephant farm since they're also breeding baby elephants for their 1:00 Baby Elephant Bottle Feeding show. I'm really glad I got to see elephants being treated so well and living freely in Thailand. There it was clear these animals were like family members to the mahouts. Here, these people used spears to poke and stab the elephant into doing what they wanted. It reminded me of the ring leader in the book "Water for Elephants."

We were taking pics and poor Mollie and Holly were totally scammed by the trainers- they were told they could pet the elephants and he's take pictures. That had trouble written all over it. They each pet an elephant and posed for a picture and before giving their cameras back, they demanded a tip. Not only did they say, "tip Madame" as a command, but then told them it was 500 rupees ($4.91). Holly's 'photographer' said he took good pictures for her. When we looked back, he didn't get any with her looking at the camera or without other tourists all over the picture. It's a good thing I was taking her pic with my camera too. I didn't even charge her a 500 Rupee tip.

At least I caught Holly looking at my camera!
Notice the stabbing spear in the guy's hands.

We didn't even stick around for the "main attraction" of the bottle feeding. We couldn't handle any more beggars or folks shoving bananas in our face to feed the elephants (which they were demanding 100 rupees/ banana AFTER people fed it to the elephant.) Terrible. Time to hit the road!

But I did take a zillion pics of the elephants because I just loved them and wanted to take them all home with me... well, take them all away from this place at least.

Leijay Resort- Our Sri Lankan home

2012-01-30T09:55:00.000-05:00

Our home for the month.

For our month long stay in Sri Lanka, we stayed at the Leijay Resort in Galle. We were about a 10 min tuk tuk ride from the Galle Fort, 15 min from Unawatuna Beach and only 5 minutes from Karapitiya Hospital. The resort was more like a guesthouse in that there were just two homes with 2 rental rooms in each. There was a flat in between the two homes that could also sleep 4 people. Each home had a shared patio, common room and kitchen, though we didn't need the kitchen since we had Jayantha! Jayantha is the chef on the property (and pretty much ran the whole place from behind the scenes) and he made some of the best food! He could make anything from the standard rice and curry to chicken piccata. It was nice to have the option of eating western food if we needed a break from all the curry. Mollie and I barged in the kitchen one afternoon while he was making our curries for the evening- we wanted to learn to make curry so we could fix it ourselves when we go into withdrawal in the US. He laughed at us but let us stay to watch. We saw him make dahl (lentils and coconut milk), a chicken curry, and 2 different vegetable curries. YUM! It seems simple, but probably because Jayantha's been cooking for a long time. I hope I can figure this out when I get back!

Rock climbing is easier than coconut-tree climbing!
I don't have monkey feet!

The staff at Leijay was fantastic. Dinesh- our tuk tuk driver- was a man of many talents. If we needed money exchanged "I do that. No problem." If we needed a ride to the beach or to dinner, "I do that. No problem." If we wanted a coconut to drink while lounging at the pool.... he and his monkey feet would climb up. No problem. One afternoon I tried to climb the trees myself, but apparently it's not like rock climbing. I could hang on to the tree for a while, but there was no vertical movement. I couldn't get my hands and feet coordinated to move while shifting my body weight. It seems easy. Trust me, it's not. Luckily, after Dinesh watched and laughed at me for a while, he decided to show off and climb a higher tree to get each of us a coconut to drink. The King Coconuts (yellow) are much different than the coconuts I'm used to... the green ones you see in Hawaii. The kings are yellow and have a sweet water inside. Yummy!

Having grown up in Unawatuna, Dinesh knows all the hot spots for us to go to.... bars, restaurants, beaches, you name it, he's got a suggestion for us. And he was never wrong! Everything he suggested was incredible. Best sunsets, delicious food, great parties, good times!

Dinesh is the pro tree climber. He went to get me a coconut.

Dinesh opening up a King Coconut for me!

Dinesh let me drive the tuk tuk! Only for a few minutes
and only on our small street, but still. I drove it!

The grounds keepers and house keepers were also so sweet and always smiling. Seriously, always smiling. There was no way you could look at Maleni and not feel good. Her joy was infectious. The Swiss owner, Yvonne, also lives on the grounds and really does treat us like family. When my classmate Holly was sick and coughing, Yvonne brought over her personal cough syrup (Syrup Maduka- some crazy molasses-smelling Ayeurvedic stuff), sent the boys out to get her some other medicine, got her some tea and offered to set her up at an clinic if needed. She really wanted to make sure we were happy with our stay. The hospitality here was incredible.

Our lizard friend!

Yvonne is also a huge lover of animals and has taken in 4 stray dogs on the property. There are many wild dogs roaming around Sri Lanka. It breaks my heart to see so many of them with bites out of their ears, or patches of fun missing from being burned or tortured by evil humans. One of the dogs, Cherie, was rescued after some boys tried to hang her from a tree... just for fun. So much for that Buddhism they claimed to practice. Needless to say, Cherie was very frightful of people and only trusted Maleni or Yvonne (probably cause they fed her!). Balu (means dog in Sinhalese) is one of the dogs who took a while to warm up to us. He always watched us from afar, not venturing onto our patio, but watching his buddy Dutchess get all our love and attention. By the last week of our stay Balu was making his way onto our patio for belly rubs. He wasn't going to let Dutchess get all our loving!

Overall a great place to stay. It really was like a home away from home. It was easy to hop on the bus (a whole other blog posting!) or have Dinesh take us on the tuk tuk anywhere we wanted to go. Any tour we wanted, they would arrange it. Any beach we wanted, they would take us. Any food we wanted, Jayantha would cook it and if he couldn't cook it, they would go out and get us take away! We couldn't have asked for a better home for our month in Sri Lanka.

Dutchess

Balu

Update

2012-01-29T15:52:00.001-05:00

Hi everyone!

I just wanted to let you know that I've updated the previous Thailand blogs with pictures so feel free to flip back through and check them out. Also, I will be posting all my blogs from Sri Lanka now that I have internet access again! I have over 1200 pictures to sort through so bare with me as I post them over the next few days.

I know the email following has stopped working so many of you haven't received an email since my Christmas blog. I'm sorry but I have no idea how to fix this. I'm tech challenged. So as I continue to post my Sri Lanka blogs, you'll just have to go to http://tracysinternationaladventures.blogspot.com/

Check back again this week!

Istuti (Thank you in Sinhalese)

Internal Medicine ward at Karapitiya Hospital

2012-01-27T10:39:00.000-05:00

After a long journey to the other side of the globe, I was finally in Sri Lanka. When I woke up to monkeys howling and playing in the trees 20 feet away, I knew I would like this place.

I was excited and nervous to start my global health rotation at Karapitiya Teaching Hospital. Despite the fact that the University of Ruhuna Faculty of Medicine is conducted in English, there is still quite the language barrier with the Sri Lankan version of English and the amount of slang that we unknowingly use. Even the everyday medical language and abbreviations varies between the US and Sri Lanka. I wasn't sure how this would pan out when I arrived on the medicine ward.

Three of us are here in Sri Lanka from the Duke Physician Assistant Program. Since Duke University and the University of Ruhuna Faculty of Medicine have an established relationship in medicine and research, many of the professors and researchers were very welcoming to us. We met with Professor Ariyananda, the Senior Professor of Medicine, and he was quite excited to bring us to Grand Rounds and introduce us to his faculty and fellow consultants before we got started the next day.

Outside the Duke Collaborative Research Center at the University of Ruhuna Faculty of Medicine.

The next day, we were thrown right into action on the women's internal medicine ward, where we spent the week. We met with the Senior Registrar (similar to our Chief Resident) and she hurried us to the first patient to begin morning rounds. It was definitely intimidating on the first day, rounding with their equivalent of residents and attendings, praying we can remember everything so we can answer any questions they start throwing out at us- we don't want to make Duke look bad!

After a few days, I was able to understand how the ward works to admit patients, complete investigations and diagnostic assessments and carry out a treatment plan. There are many similarities, but a greater number of differences between the US and the Sri Lankan inpatient wards. The overall appearance of the ward and staff, the admitting process itself, and the types of illness and their treatment protocols are notably unique.

Ward 11- women's medicine

When I first walked onto ward 11, I felt as though I had been instantly transported back in time to a 1940's army hospital. Not only do the nurses uniforms seem characteristic of the era, but the hospital itself is open-air with beds packed in so close you can touch your neighbor. With more patients than beds, some patients are left lining up with their belongings on the floor or with a make-shift mattress on the ground in the hallway. There's no such thing as privacy here! The only attempt at privacy is a green curtain that can be drawn to a close, though this greatly reduces the air circulation and increases the already hot temperatures found on the ward.

Nurses uniforms

View of Ward 9 from Ward 11.

Another distinct difference between the US and Sri Lankan hospitals is the admitting process. Patients can only be admitted to a ward on Casualty Day. While casualty typically means trauma or catastrophic event, here in Karapitiya Hospital, it simply means acute care. Each ward has their own Casualty Day, rotating every 5 days, so on any given day there is at least one medicine ward holding a Casulty Day. It's quite obvious which ward is having their day because the hallway outside the ward is lined with sick people waiting their turn to speak to a House Officer (intern). Because Sri Lanka has a public health system, and Karapitiya is a public teaching hospital, patients are first seen at their local community health clinic or rural hospital and if their illness is deemed to be beyond the capabiities of the small hospital or clinic, they are referred to Karapitiya. The patient brings their diagnosis card (pic below) to the House Officer- a laminated square paper with their personal identification information, their chief complaint, lab work if done, and treatment to date. No fancy electronic medical records here! The House Officer is the first to speak to the paitent; they do a complete history and determine if they need to be examined or treated outpatient. If they are in need of an exam, they proceed to the line for the single admiting bed where the Junior House Office and/or Senior Registrar (residents) examine the patient. They will determine whether the patient gets assigned a bed or follows up with outpatient treatment. Unless the patients illness warrents a longer stay, most patients are typically released to outpatient care after 4 days- just in time for the next Casulty Day.

Medical records -
paper patient charts, radiographs thrown in the pile, loose paper everywhere

Diagnosis Card.
Completed by the House Officer (intern) and given to the patient to carry with them to any future hospital or outpatient visits.

Patients are not provided with the same amenities they receive in the US. Patients must bring their own medical record, clothing, toiletries, pillow and blankets. The hospital only provides one pillow case and one blanket which is typically used to cover the bed. Visitors are only allowed between 1-5pm, though one person is allowed to stay at all times. It's quite a sight to see the visitors lined up behind the gate. The masses of visitors are corraled by several security guards manning the large iron gate between the hospital and outside. The only thing that gets you though that gate is a nursing uniform, stethescope, or white coat. Even our Duke liason administrator had to go in with us because she wouldn't otherwise be allowed to enter. At first I didn't understand why visitors couldn't come earlier in the day, but after the first morning of rounding and seeing the massive amounts of student learners and staff surrounding the patients, I understood!

Needless to say, patients who get admitted here are very ill. We have seen many patients with Dengue and Typhoid fever, severe heart murmurs and strokes. Of course we have heard many heart murmurs and seen stroke patients back home, however these cases seem to be much more advanced, having had no treatment or inadequate treatment from their general practitioner. There was one patient who had such a loud heart murmur that it took me a minute to realize that it was her mitral valve making all that noise and not her breath sounds! I've never head such a loud, distinct murmur in my training. I'm sure I could have heard it without my stethoscope! When I felt for her apical pulse, it was as though her heart was punching my hand through her ribs. Thankfully, the patients here are accustomed to medical students examining and questioning them every day, so it was nothing new for me to listen and palpate myself. In fact, these patients have a crew of consultants, house officers, registrars, medical students and nurses rounding on them daily- I counted 38 of us around one bed! And I thought our rounds at DUMC were packed!

Attempting to get a pic of all of the students and physicians surrounding one bed during ward rounds.

Stretcher in the back hallway.

Another interesting difference that struck me was the absence of beeping monitors and general lack of technology present on the ward. The ward seemed eerily quiet for the severity of illness among our patients. IVs were hung from a pole, but no pump to enter the patient's information and do calculations. Vitals have to be done manually at regular intervals and charted on a paper above the patient's bed. There were no oxygen tanks hooked up for the COPD patients, no controls to adjust the hospital bed for comfort and certainly no television sets. Furthermore, the lack of technology means the physicians and students must rely more heavily on their physical exam skills. It was impressive how well these physicians could hear breath and heart sounds with all the background noise and conversations amongst providers. And I know it's a silly thing to notice, but providers here are such good percussers! I can hear distinct differences in the resonance and almost pinpoint where the problem is. I hope I will be able to acquire this same level of competency in my physical exam!

The final difference I'll mention is the lack of universal precautions. There are no gloves available on the ward. Nurses draw blood, place IVs, give IM injections, etc, and none of them wear gloves. While AIDs/HIV are not common, I have already seen a patient with AIDs in the first few days and several with hepatitis C and other blood borne diseases. But it's not just the nurses; the consultants, house officers and registrars don't wash their hands between physical exams, even if they just touched a rash on one woman, or had a pneumonia patient cough all over them. In the US, you see hand sanitizer gels and foams by every patient's room and all over doctor's offices. I believe I was the only one carrying sanitizer gel in my pocket and despite not examining all the patients myself, the only one making an effort at sanitation.

I can already tell that I will learn a great deal here in Sri Lanka, both culturally and medically. I'm grateful to have already seen so many tropical diseases that are rare or non-existant in my hometown. This will certainly prove beneficial for future international aid work. Also, learning about the public health system and adapting to the difference in technology will alow me to be a better global practitioner. In the next few weeks, my colleagues and I will also participate in pediatrics, OB/Gyn, community medicine and surgery. There will be many interesting patients and experiences to come!

Weherahena Buddhist Temple

2012-01-27T10:37:00.001-05:00

On our way to Yala National Park, we stopped in Matara, one of Sri Lanka's largest cities on the south coast. Matara is home to the Weherahena Buddhist Temple, home of the largest Buddha in Sri Lanka. Standing at 39 meters in height, this Buddha sits in the samadhi position, built on top of the underground temple built back in the 17th Century. They built the temple underground and prayed secretly for fear of the Portuguese destroying it. Here are some pictures from the statue and the underground temple.

“ The mind is everything; what you think, you become.”

~Buddha

39m high!

The story of buddha and the devil.

Story lines of Buddha painted in the underground temple.
Makes it easy to follow for those of us who cannot read Sinhalese.

Galle Fort

2012-01-04T15:31:00.000-05:00

The Lighthouse

Galle Fort is like a time-warped, perfectly preserved colonial town. It's enclosed by towering bastions and is of a stark contrast to bustling bus station, fish markets and insane traffic found just outside in Galle. As you head into the fort, through the high walls, it's almost like you change centuries, or islands. The streets are relatively traffic-free and lined with old villas, churches and other mementos of the Dutch era. There are museums and churches, cafes and shops and many guesthouses and hotels. Also, inside the Fort is the Dutch Reformed Church, the oldest Protestant place of worship in Sri Lanka. You'll also find the Meeran Jumma Mosque at the heart of the Muslim quarter, near the lighthouse. Inside the fort is a predominantly Muslim community so you are hard pressed to find pork, beef or alcohol in these parts and everything is shut down by 9pm. But we enjoyed coming to the Fort for dinner or wandering around the fort walls to watch the crazy people who cliff jump of the walls into the not-so-deep sea below. We even saw one guy bleeding all over his shoulder because he misjudged his jump and nailed a rock. He's lucky he didn't hit his head on that rock. Galle Fort is also home to a now annual Literary Festival. Many British and Sri Lankan journalists were honored at this festival and there were several events throughout the week-long event. Unfortunately, we did not have enough time (or money) to attend any of these events.

Some damage to the fort walls from the
tsunami, but overall this structure
saved the rest of the Fort.

In case you couldn't already guess, Galle Fort was built by the Dutch. The Dutch followed the Portugese and precede the British as colonists. It was the Dutch who built these fortress walls to withstand enemy cannonballs. I know the Dutch aren't world-renown for their military defense or architecture in general, but they sure did something right when they built this fort. More than 300 years later, these fort walls did a pretty sterling job of keeping the 2004 tsunami at bay. The walls are still standing and I must say, did a splendid job of preserving the majority of the fort despite it's direct blow and central location within the tsunami on the Indian Ocean.

Outside the fort walls.

Eating dinner and watching the sun set from inside the fort walls.
Hard to believe the tsunami came from this same Indian Ocean
and took over this entire area in which we are standing.

One of our favorite food spots and the only
place we could find a brownie- The Pedlars Inn Cafe.

Meeran Jumma Mosque

Sitting on the fort walls- still intact after the 2004 tsunami.

Mountain biking north of Chiang Mai

2012-01-04T05:48:00.000-05:00

Mountain biking pics!

First day of mountain biking... biking along some irrigation channels first off.

Day 2 of mountain biking. Found this small village on the way uphill to our single track trail. This cute lady wanted to sell us stuff before our water break was over!

I kept up with the boys.

More farming along the route.

Sent from my iPad

Elephant Pics from Chiang Dao

2012-01-04T05:40:00.000-05:00

Since I didn't have the technology to post pics when I blogged about the elephant camp, I wanted to post a few pics here. Enjoy!

Going for a ride around the grounds.

Baby hanging on to momma.

Me feeding the 1yo baby- getting pulled in with her super strong trunk!

These guys LOVE bath time! They were just flapping their trunks and spraying the mahouts.

Sent from my iPad