Trip to Guam Part One

Sorry this is a bit delayed secondary to my internet difficulties… At the beginning of September, I went to Guam for two nights to attend and speak at at regional conference on bleeding disorders.

I was asked to participate at the end of June when I was still in the thick of working as a clinical pediatric hematology/oncology fellow on the West Coast. Part of what has surprised me is how small the world truly is — at least that of pediatric hematology. Recently, I had a resident visit and I told her that the one thing I have found in my time working ‘internationally’ is that you realize that you may have so much more to offer than you originally thought. This is where I have to remind myself to not get a blown up head…

I like this quote. “Never stop doing your best just because someone doesn’t give you credit.

Well, there isn’t much credit for doing work out here which is actually a good thing for me. If you are looking at this website because you are interested in doing work outside of the continental United States or somewhere under-resourced — know that you usually won’t get much credit except from the patients themselves.

But.. there are times when you do and when you do, it can be quite overwhelming which was part of my experience in Guam.

Already being asked to participate in this conference was overwhelming enough — and soon thereafter I found I would be the hematologist (and only physician) presenting on bleeding disorders and instructing other providers from Guam and some other Micronesian islands about what they need to know about the major bleeding disorders of von Willebrand’s disease and hemophilia. Welp… you just go ahead and say ‘yes’ was my attitude.

I was able to interface with some locals from Guam, and I realized I had a surprising leg up having worked with bleeding disorder patients here in Saipan before. I knew inherently some of the challenges they faced and knew to tailor my talk based on what was available and what wasn’t. The things that weren’t available weren’t surprising to me as opposed to someone who may not have experienced this before.

After spending some time working on the presentations I still felt quite unprepared, especially as I still wasn’t 100% sure what to expect when I arrived. But, onto the plane I went.

IMG_1246And to the Westin! with an ocean view-ish.

IMG_1245Something about a hotel room just is so nice. It may have to do with keeping the air conditioning on at all times and hot water with decent water pressure — just pointing out some of the Saipan-world problems!

I reviewed my presentation on my balcony a few times and then decided to venture out to — shopping in Guam. Even though at that point I had only been in Saipan for a few weeks, I knew I may not be back in Guam soon so figured I’d at least look around.

IMG_1247I am venturing to guess that the real owners of Din Tai Fong in Taiwan did not open this branch clearly sponsored by Asahi beer.

IMG_1250I cheated on Saipan sunsets a bit and took in this one at Guam, and then went and ate a steak with copious amount of ice tea and mashed potatoes — since apparently that’s what my body was craving the night before a big talk and because something about being in Guam meant that I should go do that.

The next morning was a quick breakfast and down to the conference area of the hotel to prep my powerpoint and scope out the attendees. While I had an idea of who would attend (various providers mostly and eventually in the afternoon patients and family members), I still was wary of exactly who would be there.

IMG_1266A little part of me was still surprised at how legitimate of a conference this was. It did make me happy to see all the effort that was being put into educating the providers and making a good experience for the patients and their families though. Again, another reminder of what a few people can do even with limited resources!

IMG_1265There were a number of tables setup already with some providers who came early to enjoy the light breakfast and coffee. I got to meet a number of them before starting as I was also running around setting up my presentation.

More to come on my talk and the festivities to follow… and next steps I wanted to take/am taking after this meeting!

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Apartment in Saipan

One of the first items on my agenda that I left completely untouched prior to arriving here was finding a home. I was fortunate enough to have a place provided for me temporarily by my work so I knew I had a little bit of time to look around. One of the reasons you cannot decide on a place prior to arriving Saipan is that the variation in what is ‘acceptable’ for a home may be quite varied. My last little bungalow house up in the forest (i just spelled that as forrest.. arch nemesis! Check out that old post about the flora around the island) was an easy find because I had to move quickly on arrival as my initial living accommodations left a lot to be desired (like, running water). Fortunately, I had been in email touch with someone who had worked at the hospital prior and endorsed the place so I just moved on in. It definitely served all of my needs I enjoyed it up there and would recommend that house to others, but this time around I knew I would want to stay somewhere different.

I really only had three stipulations..

1) It had to be relatively close to the hospital. I had already lived here before so I already had experienced the ‘expanding island’ phenomenon — where something that in the States would be a short drive away would suddenly be considered ‘really far, and I’m not sure I want to go __ because it’s so far’ — so basically out of a 10 minute driving radius of the hospital seemed unacceptable.

2) I wanted a view. Not that my place didn’t have a view from before between the trees, but I knew I’d be doing some work from home and wanted a place where I could sit and look out at the ocean. Boy did I get that! It doesn’t hurt that usually places with a view come with a decent breeze which can keep things cool without turning on the air conditioning.

3) I needed a kitchen. This is really what drove me away from my old bungalow. There was a space called the kitchen with a counter and sink, but it wasn’t really a kitchen. I do confess that I still do secretly miss my little camp stove burner, but that’s probably all I missed. I enjoy cooking enough that I wanted a place to do it. The definition of a kitchen can be variable here so yet another reason you have to see the place before you decide…

and as all things in Saipan, be prepared to be flexible. You will not have it all!

So without further ado, a tour of my place.

Let’s start with the most spectacular — the view.

IMG_1349This was from yesterday when the rain cleared away and Saipan went back to its old sunny disposition.

I have a porch (really a ledge but that you can walk on) that wraps around my place.

IMG_1235Here you can see my little car and the westward facing part of my place (it’s technically on the second floor but only the garage is under me)

IMG_1237Here’s the South facing side.

IMG_1238

And the Eastward facing side with the stairs that lead up to my place.

IMG_1320When you come up the stairs, you can see the wraparound area, all the windows and to the right is my open door.

IMG_1204This is the view you get from those windows on the inside at sunset — this picture was from my first night here.

IMG_1355That brings me to the inside of the house. This is the living area if you are standing at the door and looking in — rocking chairs strategically placed to be able to stare out over the view.

IMG_1354To your right when you walk in the door is a little area that I put my phone and wireless router and a table for work and eating with a big air conditioning machine above it.

IMG_1356Just past the table is a hallway to the right that leads to the bathroom and my bedroom.

IMG_1357I actually really like my bathroom after I found a bamboo mat and this shower curtain.

IMG_1358IMG_1359And here’s the bedroom .. I made the bed for this picture!

Outside, there is a long empty space that is the kitchen. I moved a table next to the oven (which is undergoing renovation right now!) for more ‘counter’ space.

IMG_1360You can see the water dispenser, the dish rack, etc.

IMG_1137Close up of the sink pre-move in.

And.. well, that’s it! My humble abode.

IMG_1134Come visit anytime!

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Rainy Season in Saipan

It has been raining quite a bit over the past few days and weeks although there are definitely days that the sun shines through. Actually, most days there is sun — but that does not mean that there was not a continuous downpour the night before. In the mornings when I am on the way to the gym, I have had to fight the deluge and sideways rain sometimes. I actually seemed to totally forget about what the rainy season was like here. I do remember the rain (which I actually enjoy) but just not that it would rain so hard or continuously.

Because the island of Saipan is so small, clouds full of rain can move through rather quickly.

IMG_1095IMG_1099

These are pictures taken from the exact same spot taken, per the timestamps, 4 minutes and 53 seconds apart. Look back.. you can see Managaha Island and then a few minutes later, practically gone because of the pouring rain cloud.

In most cases, you can expect the heavy portion of the rain to pass in a few minutes because of the quick moving clouds over a small area.

The temperature overall stays the same though although the level of humidity does slightly change before and after the rain (not as much as you would hope though)!

There are also days when it rains here and it is still sunny — what I call sun showers. I caught one of these on video while watching the sunset. This is a video that I took sometime the last time I was living in Saipan.

Enjoy both the rain and the sun! While I secretly wish for fall weather, I’ll take this variety for now!

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New and old procedures

During your training to be a doctor in the United States, you have to decide which specialty you want to become. A common first step to the decision is deciding between a “procedural specialty” or perhaps what is described (I don’t like what this implies) an “intellectual specialty.” You can see the rift that can happen between the two. Something on the lines of the rivalry or brunt of jokes between violists and the rest of the orchestra. (FYI, violists = people that play viola.. not violin) Basically it is a separation between the physicians who primarily do procedures (surgeons, orthopedic doctors, ophthalmologists, gynecologists) and those who don’t (medicine, pediatricians, psychiatrists, neurologists, etc).

It isn’t actually so black and white actually but when you are making that first decision, it can feel like that. You worry that while you enjoyed anatomy, by choosing pediatrics or whatever you will never be able to use a scalpel again. On the opposite end, you worry that all you will be ever seen as is a person wielding a power tool who actually truly enjoys the physiology.

For people that had that struggle, they end up seeking out procedures or seeking out a practice that allows them to think through differential diagnoses more. In the case of pediatricians, you may choose to be a subspecialist in cardiology where you work a lot in the cath lab. In the case of surgeons, you focus your practice on organ systems that involve more of a combination of medical care. You get my drift.

As you can probably tell, I was one of those people who was afraid I would lose my ability to do procedures. I sought out my share during residency — volunteering for suturing (and one time learning from a mistake I made.. mea culpa!), lumbar punctures, watching as many surgical procedures as possible, tapping ventricular shunts, doing splinting, putting in central lines, and on and on. I knew I was interested in under-resourced care so I spent some time learning about the ultrasound machine and did some time in radiology.

Well interestingly, this time in radiology paid off this week (in a way)!

There was a patient who was in need of a VCUG (voiding cystourethrogram) which is a special test to look at the ability for the bladder to correctly hold urine and… well, pee it out in the right direction when it was supposed to.

This used to be a test that was done much more often until research more recently showed that finding the results of it for routine cases was not that useful for the patient long-term. In this case, there was an infant that had a urinary tract infection very early on in life with pathologic findings on a kidney ultrasound that prompted this test. I was asked to help perform the test as a physician. In most cases, this would be performed by a radiology specialist but fortunately, I had at least been involved in a few before.

Not to my surprise, the equipment was just slightly old…

IMG_1312As we turned the system on (the fluoroscopy machine) and I saw this pop up on the machine — I literally thought of my old tetris game as a child!

But technology has a way of surprising you in that the machine was truly built to do just what it was designed to do. Knowing the basics of the test and the principles, I was able to put together what needed to be done to get the information we needed.

IMG_1311

You can see the machine in the background through the window and we set the machine to give the right dose of radiation.

I then inserted the catheter that was required and instilled the special dye that would allow us to see the bladder filling. Having seen this procedure before and having talked to radiologists before about the concept behind the procedure, I was able to recreate what was required. That is one of the things I truly enjoy about this job — using your brain to put together the pieces of what you have learned to do a test or give a treatment that you might not have been in charge of before, but can be involved in now. Without this expertise, the child would have had to been sent off island on a plane to get this done.

I instilled the dye and took the appropriate pictures, waited the child to urinate and took the pictures required again. We got all the information we needed from the test and the family was able to bring the child home immediately.

IMG_1313More views of our old but very much functional machine.

These are the things I find rewarding about my work here, and soon I will have the interpretation officially of the test because I was able to electronically send the images to a trained radiologist to interpret for us.

I am glad that despite choosing the field of pediatrics (and peds hematology/oncology), I have preserved some of my ability to do procedures. I am fortunate that my choices didn’t turn out as black and white as I originally thought. In fact, tomorrow I am scheduled to do a bone marrow aspirate on a patient too! I’m grateful to be using all my skills from both residency and fellowship here.

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Internet Connectivity Achieved

I would like to declare that I have access to internet at home and would like to share some tips about the current internet status of Saipan and the CNMI.

First of all, as I have been told before.. internet is the most expensive here in the Commonwealth of the Northern Marianas Islands (CNMI) than any other place on United States soil. From what I have been told the reason is because there is only one connection for DSL running from Guam underwater and really no other reliable way to get internet (although there is also cable that exists).

Besides the copious activities of exercise and outdoor.. ness.. and random cooking adventures at home, there are very little other sources of entertainment here (although I do read a number of books… except now I use a Kindle Fire which means I download my books from the internet). The internet is my connection and entertainment all rolled into one.

After a LONG saga about my phone — an iPhone5 which I found was not really compatible with one of the systems on island (IT&E) — I finally changed to the other phone company (Docomo) despite the hassle of changing my number in order to get reliable phone and 3G service. I have very little to complain about since data for your phone is something I very recently (aka the last time I was living here) did without. Having data on my phone gave me access to essentials like email, but not having internet was becoming more and more difficult.

(How else would I rant about it online for all to see.. haha, just kidding!)

As with anything on island, a lot of patience is generally required for anything that requires more than one step. Unless you clearly are at a store purchasing something that you can see in front of you, purchasing anything else is not a sure deal. I had to draw a map on a piece of paper to my house since we do not have reliable street names or addresses here to show them where to connect my landline phone and DSL line. A few days later when I still was not connected, I finally got ahold of someone who came and said that actually my old house from two years ago was what was connected! Somehow that little map I drew from two years ago still existed and apparently made it into the hands of the person doing the connection.

Then, a week later, I still had not been connected and another person came out to get me connected correctly this time. But, the internet needed to be activated by yet another person. Several phone calls and hastily typed iphone emails later, I finally got my internet connected. So, here I am now updating my blog.

Cheers to internet connectivity. I will not lie, the first thing I did once my internet was connected was watch a television show streamed online — and then send an email to make sure I would not get charged for the weeks it took them to connect my internet!

For anyone that is potentially moving to Saipan, know that internet will be expensive and will probably be more complicated than you expect to setup but.. I consider it a necessity nowadays so you just have to learn that it is one of the things you have to deal with here in island living. And then embrace the good things like.. this…

IMG_1205More to come now that I have internet access.. here’s a picture from my balcony of a recent sunset. Up next: new house tour, Guam hemophilia conference, and more!

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New Saipan Music Video

Last time I was here, I heard about a Kpop music video that featured some of the wonderful parts of Saipan. Read more about it here.

Like I mentioned in that post, Kpop embodies a lot that makes up Asian pop culture. In the States, there are some people who are enamored with Kpop and it has made its way into pop culture around the world.

So, while the last video featured some of my favorite scenic places like Banzai Cliff — this one was a bit different. I saw it pop up in my Facebook feed from a few Saipan friends over the last few weeks.

I still don’t have internet access at my home but am eating breakfast at a place with wi-fi and have been waiting to post this for awhile.

This video was so fun for me to watch because it didn’t really involve the places that are touristy in Saipan, but some of the places I frequent ALL the time.  (The carwash place I probably drive by at least once a week and is pretty much just across the street from the hospital)

There have been two new doctors that have come to the island recently and one of the underlying themes that has been vitally important to them has been the presence of a grocery store that somewhat resembles what they may have frequented back in the States — rather than a catch-all store that may be more common in Asia. The first new doctor I talked to had gone exploring and was really quite unsure of what I meant by “there was definitely grocery products available on island” as she searched high and low for reasonable appearing aisles.

Immediately I corrected her… slightly appalled. Where did you go?! Have you not been to Joeten yet?

Joeten…. seriously without this place, I’m not quite sure how things would work out on island for me. While I don’t shop at Joeten exclusively (sorry), I do expect to be in Joeten a few times a month for essentials. As I have been moving into my new place, I knew I had to visit the Joeten shopping center in Garapan that is actually more like a Target with household goods as well. The second new doctor on island actually bumped into me at Joeten as she was happily filling her grocery cart with essentials for her and her family as well. In fact, I probably mention Joeten a few times a day to my patients even!

IMG_1220 Joeten Garapan shopping center.

IMG_1211Frozen meat/goods aisle made famous in aforementioned Kpop video.

IMG_1209Clean, familiar aisles. It must be the domestic side in me talking but these aisles I can truly say do make a small part of my soul satisfied.

IMG_1212Over the counter medications in aisle 15A? A common phrase out of my mouth in the clinic is “don’t worry, you can easily find it at Joeten”

IMG_1213Fancy some artificial flowers? Visit the Arts and Crafts section of Joeten.

IMG_1210Last but not least, a can a spam? Which flavor do you prefer? In my life, I have never purchased or opened a bottle of spam — and do not plan to — although you can get your fix at Joeten anytime apparently!

*Side note: this is not a paid advertisement… although if you are associated with Joeten (ehmmmm), I would not be ashamed to take some payment! (just kidding!)

Glad I can share about one of the places that is very much a part of my daily life here in Saipan — and awesome to see it in a Kpop video. Hope to share more Kpop with you soon from this island!

 

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Transport continued

Continued.. from the Guam airport on my second layover. (It is certainly more relaxing to not be transporting a patient through these layovers!)

Once you effectively get on the plane with the patient, you hope for the best on the layovers and these were actually very smoothe. It tends to be, as I mentioned earlier, a search for plugs and fingers crossed for battery life and no delays but when things go smoothly, it isn’t so bad. I think having done a prolonged flight with multiple layovers to the west coast made this flight which is just 4 hrs from Guam to the Philippines and only one layover in Guam feel a lot easier.

We arrived Manila and offloaded on the plane and were expecting an ambulance on the tarmac. We do this for most of our intubated (breathing for them) patients in order that we can send a separate person in to go through customs. This time though, they stated that there was no ambulance. They (and we) assumed that the ambulance company didn’t get the memo or the correct clearance and were waiting on the curb, where most of our patients are picked up. Well, you can see where this is going.. no ambulance on the curb either. Fortunately, this is where trouble shooting comes in handy. I had an experienced team member with me who had an available phone that worked there and we found out it seemed the ambulance had not been dispatched. If you can bag someone for a whole flight without support, no reason for an ambulance now! We hoped into a car and got to the hospital.

After dropping off the patient, we went to a hotel for an overnight break and a quick shower. We happened to get some Papa John’s pizza too! I also got some McDonald’s for breakfast — being in a big city means that fast food is readily available of course!

And.. now I’m on my way back and back to business as usual — although technically business as usual seems to include these transports!

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