Recently, I had the opportunity to report on the challenges of public health and peacebuilding in Nepal in The Lancet: Download file

Although my main clinical interest is in surgery, the Nepal experience has opened my eyes to the fascinating intersection of public health and peacebuilding. Most importantly, it has taught me to challenge assumptions and dive beneath the superficial discourse to arrive at my own narrative and understanding for what I see and experience. Although this awareness arose in Kathmandu, it continues to inform my research and my perspective back in Palo Alto.

Entering Juvenile Hall, I went through two locked doors and followed a yellow line to the control desk where they pointed me to the medical clinic. I couldn't help but feel a bit like Dorothy, or more aptly, the Cowardly Lion on the way to meet the Wizard of Oz. In this case, the Wizard of Oz turned out to be Dr. Jerry Klein, who definitely showed no penchant for smoke and mirrors and arriving and departing via hot air balloon. Immediately, he set me to work.

As part of the medical care at Juvenile Hall, each kid that comes in undergoes a full physical. The first patient I interviewed was in because he was riding in his cousins car, and when they were pulled over for a routine traffic violation, the police discovered drug paraphernalia (mushrooms and scales) in the car. An important part of the adolescent physical exam is the HEADS assessment (Home, Education, Activity, Drugs, Sex). After hearing his story, Dr. Klein came in and I presented the patient to him, and then I had the enviable job of checking for inguinal hernias. Cough, cough.

This past week has been an amazingly enlightening experience. I never for once felt unsafe at juvenile hall, and all my apprehensions quickly dissipated each day as I was greeted by the friendly nurses, medical assistants, and clerks each morning. Speaking with the patients, my eyes were opened to life in its grittiest details. At the end of the day, I realized that despite whatever crime that these kids were accused of, they were just that--kids. The toughest gang member would suddenly become the 14 year-old kid that he was when we took out a needle for a TDap vaccination.

Some of the kids were from average families who just were at the wrong place at the wrong time, but a significant majority of the kids came from group homes, children shelters, or foster homes. One young 12 year-old boy had bounced from group home to group home for months. Many were suspended from public schools and had to go to alternative independent or remedial schools, and while, most of my kids answered that PE was their favorite class, I was delighted when the rare kid would answer history (I was a history major in college) or chemistry.

Of course, often times I felt I had trouble connecting with my patients. I had never been in a gang, never heard of a group home until this week, but what I had been was a kid. And remembering what it was like to be an awkward 14 year-old (some might say I'm still awkward, but I beg to differ), scared, and away from home helped me gain at least some measure of understanding of what my patients were going through.

Most importantly, I was there to listen and learn. The beauty of providing medical care at Juvenile Hall is that the kids have no place to go. Your patients in an outpatient private practice may have soccer practice to go to or a date that night, but my kids had no other place to go but sit there and bear with my (I'm sure) boring and seemingly irrelevant questions.

I also learned quite a deal about gangs in the San Jose area. Bloods, crypts, Nortenos (Northerners), and Surenos (Southerners). One of my patients even suggested that if I were in a gang I would most likely be a Crypt--apparently its the Asian gang.

I wasn't alone in all of this. Along the way Dr. Klein encouraged me to explore these social issues, and he always made sure to call me over when he saw some pathology in a patient that he was examining in the other room.

One patient stood out for me. Joe (I changed his name) had run away from his group home, and in the process of jumping over a dry creek bed, ended up dislocating his knee. The knee joint is a fairly strong joint, and you need incredible force to completely dislocate it, tearing the ACL, PCL, MCL, LCL. When I first met Joe he was in the back of the infirmary of the clinic, a small quiet room away from the hustle and bustle of the clinic. I felt I was entering a solitary confinement room. Joe had all sorts of orthopedic hardware sticking out of his leg, a rather dramatic sight for the uninitiated like myself.

Over the course of the week, I got to know Joe. He had been in Juvie previously for hitting his father with a tequila bottle, and ran away from the group home because another kid and him would get into arguments over who got to use the phone. He also told me of his history of what sounded to me like schizophrenia. When I had down time, I would sit down next to him in his bed (inevitably waking him up from a nap), and just shoot the breeze. He told me about his faith and pointed out his favorite passages in the Book of Mormon. He told me about his desire to get back to his unit and be with his friends. And he got up excitedly and smiled each time he heard me entering his room. He asked how tall I was, and asked me to guess how tall he was. We talked about basketball. And each time as I left he would shake my hand, and I felt that for a split second I wasn't a medical student seeing a patient, but a friend visiting someone at the hospital.

That feeling raised an ambivalence within me. Could I be friends with somebody charged with assault and battery? Unfortunately, I don't know what happened with most of the kids I saw this past week, whether their cases were thrown out or they were sentenced for longer stays at Juvenile Hall or the California Youth Authority. Some were in for minor crimes, some were in for armed robbery or grand theft auto, but not once did I consider them criminals. I am not in the legal profession with their black and whites, right and wrongs. Luckily, I am in medicine, where we have the luxury of not having to view people as good or bad, but only as sick or healthy. For all they did, didn't do, or were accused of doing, the kids at Juvie were just kids, my kids, my patients, for one inspiring week.

After the orientation in the morning, we went off to our sites. After a brief (i.e. 5 minute) orientation at the Valley, they told us to go grab a patient and get the day started. Two of the other students had already gone through clerkships, so they actually knew how to see patients and properly interview them. My classmate and I looked at each other with fear in our eyes. This was our first hour of our first day of our first month of our first clerkship ever. We had no idea what to do.

In fact, I kind of just froze up. After only interacting with board review books, the computer interface of Kaplan Qbank, and my trusty thermos of tea for the last several months, I think I've completely lost whatever minimal social skills I had before I started studying for boards. I had no idea how to talk to normal people anymore, much less crying and sick five year-olds and their anguished parents. Luckily, the attendings sensed the fear in the air, and we ended up spending the next hour shadowing the attendings.

But the halcyon days ended quickly, and we were gently told to leave the nurturing nest and to test out our wings. I grabbed the first chart on the list, and I saw that my patient was a 5 day old baby girl here for just a weight check.

I figured that I could handle this. Weighing a baby isn't too hard. I jauntily stepped into the room with all the naivety of a fresh-faced third year medical student. I greated the family (mom, dad, two brothers), and pulled out my arsenal of pediatrics pleasantries that I had watched on the training video the night before (apparently, Tickle-Me-Elmo is the way to go, little kids love Elmo and always stop crying when they see the fuzzy head peaking out of a white coat packet). Of course, the five day old baby paid me no attention whatsoever. I asked what I could ask about bowel movements, feeding habits, etc of the baby, but really, I ran out of questions after about 46 seconds. I then smiled awkwardly and asked the parents if they had any questions--my favorite stalling tactic.

Since the chart said the reason for the visit was to weigh the baby, I figured that I could manage that. So Daddy and I plopped the baby unto the scale, and with lots of hums and hmms and all the gravitas I could muster I recorded the weight of the baby.

I thought my job was done. I went to my attending with confidence that I weighed the baby in an irreproachable manner. What ensued was a hour-long teaching session of all the things I should have done. Apparently, they were concerned about the baby's bilirubin levels, and I had to go back and track all the bili levels and then plot it on the Bhutani curve. And then I had to calculate the change in body weight from birth to discharge to today and figure out if the baby was gaining enough weight. And then I had to figure out if the mother was making enough milk. What I thought of as simply measuring the weight of the baby became an all encompassing check-up of the baby. Luckily, the attending was extremely patient, and took an hour out of her busy day to walk me through the proper management of a baby who wasn't gaining weight and the proper monitoring of bilirubin.

The most confusing part of this initial patient encounter of mine was right when I first walked in at the beginning of the H&P, the parents informed me that the baby's belly button had fallen off. I thought I misheard them and asked them to repeat it, and sure enough, they said the baby's belly button just fell off. Incredulous, I inched closer to the baby and with a sigh of relief pointed to the very much present belly button on the baby, and continued on with my merry H&P.

As I was about to step out, the parents held out a little black nubbin in their palm. And then it clicked! That was the belly button they were talking about! I sort of freaked out. In all my years of schooling, it never occurred to me that the little stump of the umbilical cord falls off a few days after birth, leaving behind the belly button! In my pristine understanding of the world, I thought babies emerged with cute little belly buttons.

So I rushed to my attending screaming, "The belly button fell off, the belly button fell off!" She looked at me, shook her head, and I thought I heard an audible sigh.

That concludes my first day of my pediatrics rotation. It is remarkable how much I learned this afternoon. I'm looking forward to the rest of the rotation. Next week, I'm heading to juvenile hall to rotate through the clinic there. Don't lose your belly buttons.

So the big day came on June 23. The night before I went to bed at 10PM, which is quite early by my standards. Of course of all the nights it had to happen, I couldn't fall asleep on the night before arguably one of the most important exams of my life. I tried to sleep, but kept on tossing and turning for the next several hours, until around 1AM I decided to get up and take a hot shower, hoping that it would relax and calm me down.

Luckily, my roommate (an electrical engineering PhD student from good ol' Belgium) was up, and I solicited his advice for calming my friable nerves, figuring that a scion of the old world would surely have a remedy for my plight. With a straight face he told me that he too usually couldn't before big tests, and that the only way to deal with this antediluvian insomnia is 1) drinking a mug of warm milk and 2) counting sheep. The best thing about this is that he actually meant this. Drinking warm milk? I think he thought I was a little kitten or something. And counting sheep? Seriously?

With no better solutions, I made myself a mug of tea (in lieu of the warm milk), and then went back to bed. Still not being able to sleep, I decided to resort to the roommate's backup plan of counting sheep.

Counting sheep is the most worthless exercise ever. I didn't even know what counting sheep meant, seeing as I had no sheep or other ungulates residing in my room. At the risk of sounding like a complete idiot, I almost asked the roommate the protocol for sheep counting, seeing as I was a novice in that regard. But I figured that it would be most prudent to salvage what remained of my dignity and retreated to my room to count not sheep, but my potential USMLE Step 1 score. Starting at 0, I fell asleep around 130. 130, while a respectable IQ score, unfortunately is a laughable step 1 score, so my sheep/score counting did not bode well for the big day.

The big day arrived, and it was remarkably uneventful. I was on auto-pilot for the 8 hours of the test. To be honest, finishing the test was altogether anti-climactic. I half expected ticker tape and confetti to fall from the ceilings or doves to erupt into flight at the Prometric test center, but none of that happened. So I drove home and got some much needed sleep.

Today I saw patient who committed suicide by eating a box of rat poison. As you medical types may know, rat poison is essentially coumadin. After downing the poison with a cup of coffee, the patient looked down and read that it would take at least four days to kill the mice, and he being much larger than a mouse, he figured it would take over a week. A few days later, he was shaving and ended up bleeding uncontrollably, at which point he went to the ER of the VA hospital. He ended up becoming unconscious and spent several days in the ICU while the doctors scrambled to figure out the coagulopathy he had. Eventually, he told the doctors of his suicide attempt and was transferred to psych ward.

Speaking to him, it really hit home how much psychiatric and emotion health plays into our overall health. Because of my interest in surgery, I have tended to view disease as physical and biomedical manifestations. But listening to his story (the loss of a loved one and subsequently all his life savings and his home), reminded me of the truly human aspect of medicine--not just pathology, physiology, pharmacology, but the quotidian fortunes and misfortunes of life.

I have to admit before I started this psychiatry block, I approached psychiatric illness with more than a little bit of skepticism. Having no real frame of reference, I wondered why these patients couldn't just tell themselves to get better. But after seeing patients with schizophrenia, delusional disorder, PTSD, and major depression, I realized that they are truly suffering and sick--that psychiatric illnesses are just as debilitating as medical and surgical ones and as worthy of all of our attention. Seeing the effects of the numerous antipsychotics and antidepressants have been eye-opening as well--we really can make these patients better.

The main approach we take is exposing mice to either acute or chronic injury. If you guys paid attention in your English and Lit classes in grade school, you'll remember the story of Prometheus. A rather nice chap, Prometheus stole fire from the gods and gave it to Man. The Greek gods being the rather selfish bunch that they are, got rather upset and chained our protagonist Prometheus to a rock. Each day a vulture would fly to the rock and peck away at his liver. Fortunately, his liver would grow back every night. Unfortunately, the vulture would be there again the next morning.

Long story short, the liver is the only solid organ that can regenerate. The theory is that in response to acute injury the hepatocytes proliferate and hypertrophy. However, in cases of chronic injury where there is damage to the extant hepatocytes, oval cells become a transient population of proliferative cells that can help to reconstitute the liver. Our lab studies the role of beta-catenin in that proliferative response, with the hypothesis that pertubations to beta-catenin signalling in oval cells may be responsible for liver cancer.

The liver happens to be my favorite organ--afterall it is the unsung hero of the body. I've been doing research since high school, starting at M.D. Anderson with my initial projects on minimal residual disease detection of ALL with PCR and cancer gene expression profiling using cDNA microarrays (back then microarrays were still fairly novel).

Enough reminiscing--I spent the day checking on my little cells growing in soft agar. Watching the cells does not make them grow faster. I also ran some gels for a PCR I did a week ago. It's tough scheduling lab in between classes, meetings, and such. What normally would take a few hours during the summer, ends up taking a week to do during term time.

The attendings have been extremely nice and welcoming, taking time out of their busy schedules to critique our presentation skills and go over pertinent physical findings.

I had a really interesting case today of a 40-year old man who presented with complaints of pain around the left orbit that has progressively worsened since December. He also had fairly prominent proptosis of the left eye. He's been in the hospital since Thursday, and the physicians here have empirically treated him for orbital cellulitis with vancomycin, cefapime, and flagyl to cover potential bacterial or fungal abscesses. His CT showed a large mass behind his left eye that was causing the proptosis, and they now believe it to be a neuroendocrine tumor.

What was most memorable for me thought was in the course of the hour I spent with him, he did not mention the fact that he was HIV positive. I asked him about his past medical history and HIV never came up, and it was only when I asked about his current medications that he mentioned he was taking Atripla, a new combination pill of nucleoside and non-nucleoside RT inhibitors. Of course, this opened up a whole avenue of history.

It's scary to think that I could have also missed such an important part of his history. Luckily, our clinical practicum is mostly for us to practice, as we are not yet responsible for managing the patients yet. The patient also had a really compelling story--he had a detached retina from physical abuse at home when he was 15, leading to loss of vision of his right eye. As a result of his family issues, he's now dealing with PTSD and depression, and talking to him made me appreciate the importance of the patient-doctor encounter and the medical interview. For the first 45 minutes he was a patient with proptosis, but then all of a sudden the details of his life were filled in and he became a more complete individual and not just a patient.

It was nice to be out in nature today. With the sun radiating over the hills and ground squirrels chasing each other through the dry grass, one feels that spring, although not yet arrived, is just waiting around the corner.

It was a fairly traumatic experience. Needless to say, I ducked and covered my face, not wishing those sharp yellow talons to rip me apart. Apparently, the hawk was going after this squirrel and the squirrel, being the clever creature that he is, noticed him coming and ran up the tree, at which point the hawk had to swerve from his dive in order to not smack into the tree. Since I was standing next to this tree he almost hit me as he swerved. I was afraid that since he was disappointed in missing his meal that he was going to eat me instead. Luckily, my cowardly ducking and hiding convinced him that I was not worthy enough as a meal.

The most embarrassing thing was that throughout this entire ordeal, there was this guy standing by the CCSR with a coffee in his hand laughing at the whole situation.

Of course, out of all the med students in all the med schools in the world, I would be the one to be attacked by a hawk on the way to my neuro exam and then be made fun of for it.

Back to the books!

I started reading Thomas Wolfe's You Can't Go Home Again on the flight to New York from Houston, and I felt it oddly appropriate. My mom and I were heading to New York for a week to stay with my sister and her little piece of (rented) Manhattan swarming rock.

We arrived on Christmas Eve, and I immediately donned an apron and started cooking. We forwent the traditional turkey for my little menu. We started off with mussels a la escargot, a recipe courtesy of my Belgian roommate Kristiaan, followed by roasted magret (duck breast fillet) with a side of seared fennel, and concluding with some pastries that Stacey had picked up from Buchon, one of my favorite pastry places in New York. We had a bottle of wine that my sister contributed to the evening's festivities and we were quite stuffed by meal's end.

After dinner we met up with my friend Eric and his girlfriend Sharon who had been visiting the city for the last couple of days. I've known Eric since I was in eight grade, and we've shared many exploits in German class from acting in atrocious Rollenspiele to getting lost on the Philosophenweg in Heidelberg. Feeling very touristy and in the Christmas spirit, we took a little photo among all the other touristy folk by the Christmas tree in the Rockefeller Center.

The next day we walked along 5th avenue and walked along Central Park. We then had afternoon tea at the Four Season's which was a lot of fun. We spent a few hours there drinking tea and nibbling on little scones and crumpets next to a blazing fireplace and it felt very Christmas-y.

We also managed to catch two Broadway shows. The first one we say was "Company." It was my mother's first Broadway show, and she was quite excited. IIt wasn't a traditional song and dance kind of musical. There wasn't a pit for the orchestra/band; each of the cast members had their own instrument which they played when they weren't speaking/singing. There wasn't much of a plot, but it was a series of short vignettes revolving around a 35-year old bachelor named Bobby and his married friends discussing the woes and virtues of marriage. Kind of a dark comedy, and so dark that I fell asleep halfway through.

We then saw "The Producers" a few days later which was pretty awesome. I'd seen bits and pieces of the movie before, but the show was spectacular. I couldn't stop laughing and left the theater skipping and humming "Springtime for Hitler" until I realized I was getting weird looks from passersby.

I also met up with a few college friends. I hung out with my blockmate Jon quite a bit, and we ended one of the evenings with a pubcrawl around New York of which my memory of it was very dim. I also got to see my other blockmate Justin from London, and the three of us had quite the feast at a dim sum restaurant in Chinatown. I also met up with my friend Tamara from college; we were walking down the road looking for a place to sit down and chat and within a span of three minutes I ran into two people from Harvard that I hadn't seen in college. I guess New York's a small city.

All in all I had a good time in the Big Apple. I had lots of good food, the highlight of which was a six-course extravaganza at the two Michelin star Daniel. We also spent a couple of afternoons at the museums, and there was a glorious exhibit on Spanish painting at the Guggenheim.

Now I'm back home in Texas enjoying the sun until I return to the rainy season back in Palo Alto.

Here is a picture of me pondering and waiting for my hair to turn blonde:

Remarkably, I'm a few years older, my hair is still black, yet all that gibberish makes sense to me now. I grew up in Sugar Land, Texas after a few stints in New Jersey and California. The motto of my town is "Sugar Land...there is no Equal." Get it? It gets me every time. Every time I was asked where I was from my friends would laugh at me and ask me if I was seriously from a place called Sugar Land. Then they'd ask me if I actually meant "Candy Land." Apparently, there's a board game named Candy Land, that I somehow neglected to play growing up. Maybe I was too busy playing doctor or something (I actually wanted to be an archaeologist, Indiana Jones style...) Anyway, to get the record straight, I don't know King Kandy, I never went out with Princess Frostine, and Mamma Ginger Tree and Gramma Nutt aren't related to me.

I did my undergrad at Harvard, where I majored in History and Science. This, again, is a subject of much confusion to my friends. They ask me if I did history or science or both. I loved my major--I took history/anthro classes, science classes, and history of science classes around a theme. The first two years my coursework revolved around the intersection of art and 19th century evolutionary biology (I was the world's expert on these glass models of marine invertebrates, but that may have been due to the fact that I was the only one to have ever studied them). My last two years focused more on medical anthropology and history of medicine in the developing world. I wrote my thesis on the role of Western and Chinese medicine in translating modernity and forming national identity in Taiwan.

At Harvard I was a coxswain on the crew team, and I had the dubious honor of being the only member of the Harvard Varsity Lights to not have passed the swim test. They were going to make me wear a life jacket, which would have made me the laughing stock of the EARC. Luckily, I never drowned each time I was tossed into the Charles so they kept me around. Here's me safely on the shores of the Charles with my sister Stacey (or the Chuck/Rio Carlos as I'd like to call it...)

So now I'm a second-year medical student at Stanford Med. I've loved every minute of it. Last Spring Break a group of my classmates brought Stanford Med to the open ocean:

Yes, that is me in my white coat sliding down and saving a drowning kid. Nevermind that it was staged for a little promo skit for admit weekend. What matters is that, hey, it's all for the kids.