Colombian roads, El Parque del Cafe, and having HIV outside of Cali

There’s a road in Cali called Calle 5a. It’s the main north-south thoroughfare through Cali. You pretty much can’t avoid it. No matter where you’re going in the city, somehow, you will end up on Calle 5a. Parts of it almost feel like Storrow Drive in Boston, an elevated roadway, with exits to the main streets, graced by billboards and greenery. Yet in other parts it is indeed just busy street. And although there are recommended pedestrian crosswalks above, many people think it’s a good idea to try and dodge the traffic and cross, like the old man carrying several large boxes on his head, who we almost hit in our taxi last week. There’s also the men hauling huge rickshaws covered in fresh fruit down the middle of the road, kind of like getting stuck behind a horse cart. Calle 5a also becomes the Big Dig like tunnel I wrote about earlier. On a weekday morning, as early as 6:30 am, its lanes will already be congested with traffic, with motorcycles zipping along in their own private lane to the right. Don’t try and go above the speed limit though, because they’ll take a picture of you and mail you a ticket. But if you drive through the tunnel at 7 am on a Sunday, as we did last weekend, you’ll have it all to yourself.

Nora and I were driving through the tunnel with Jaime, our lovely attending and stand-in father in Colombia, who was taking us to the Parque Nacional de Café, near the city of Armenia, about three hours to the north.  The drive takes you on well-maintained highways and roads, slowly winding uphill, but only as far as the foothills. Interesting side note that although the highways are built by the government, they are then sold to private companies to maintain. Although there are several tolls, these seem worth the high quality roadway.  There are a few small cities and towns on the way, with businesses and churches and schools and dwellings that all look fairly comfortable. This is not the countryside poverty I’m used to seeing. 

In the rainy season, which it is now, everything is delightfully green and fresh.  Muscular cows graze lazily, as they slowly make their way up the sides of the dramatic and steep hills, and continue partaking in the juicy green grass. Apparently Colombian beef is tougher because the cows are forced hard to walk up hills, whereas Argentinian beef is softer because they graze in flat fields. So says Jaime.  Even the highway rest stop, where we stopped for some breakfast, was a delightful change from ours at home.  A large thatched roof protects an open space below, complete with full cafeteria, bathrooms with showers, and a convenience store.  Despite the gas station and rushing cars on the highway, there was something peaceful about sitting below a thatched roof, with a quiet breeze blowing through, and birds circling above, while we enjoyed coffee and arepas.

The Zona Cafeteria, the coffee region, is mountainous and green, with a slightly fresher climate than in Cali. The winding, bumpy road leading to the park is lined with small inns and farms, serving as a popular weekend escape for Colombians. The national coffee park is an amusement park, museum, performance space, getaway space and chance for the Colombian coffee growers to promote their product as the best coffee in the world. Juan Valdez watches over you from the minute you arrive, from the Juan Valdez café, to the coffee museum propaganda to the gift shops hawking his goods. There was a beautiful, shaded winding pathway down the side of the hill, from the entrance of the park, to the amusement park below. Along the path were coffee plants, and a bamboo forest, and a river. In the distance were mountains shrouded in clouds, with far away cities and farms in the valleys below.

After walking through the model coffee region town square, complete with food courts and gift shops disguised as authentic houses and buildings, we boarded the train from the train station. Along with 200 other people, mostly in their 50s and 60s, our train made its way at 5 mph to the other side of the park, while all the passengers cheered and waved at everyone we passed. Jaime told us, whenever you put a bunch of Colombians together, even if they don’t know each other, it’s going to be a party. Nora referred to the train as the roller coaster for the old people. Our train took us into the heart of the amusement park, and so how could we not partake in the excitement of the bumper boats.

The best part of the visit may have been the show. Impressively choreographed and costumed, this 30 minute show had several large group dance routines, each highlighting the history of coffee in the region, as well as characteristic costumes and music from different parts of Colomiba. There was even a little aerial silks action a la Cirque De Soleil. As I sipped my Juan Valdez Café coffee, staring out at the green mountains, I was sad to be leaving.

Thus began another week in Cali, another week to get to know the hospitals here, and better understand the resources here, and how they work.  I saw a patient in the HIV clinic. It was his first visit. He carried with him a large manila envelope full of medical records from…The Mayo Clinic in Rochester, Minnesota. That’s right, my first patient in the HIV clinic was a Colombian who had been living in New York for 18 years, but then got deported after doing a yearlong sentence in prison in Minnesota. He was excited to speak English to me. I tried to keep speaking to him in Spanish. He told me about his children and their mother in New York. He told me how depressed he got after leaving prison and being deported. He stopped taking his medication altogether. That was two years ago. Previously his HIV had been very well controlled and he had never been hospitalized. Now he was finally presenting for care, with many months of fevers, weight loss, cough and shortness of breath. “I did a really stupid thing.”  We sent him from clinic to the Emergency Room to be admitted to the hospital. He would need a lot of workup and care. He had also traveled 2.5 hours to get to the hospital, from the port city of Buenaventura, where the medical care is apparently quite lacking and minimal, particularly for HIV+ patients. Later that day we passed by his stretcher in the ED, laying there with an oxygen mask, looking tired. I found myself thinking about his perspective on this experience. A Colombian, having previously been a patient in the US medical system, and now sitting in a Colombian ED, one of the largest, busiest, and most bare bones EDs in the city. Here, as in Rwanda, as in many other countries, patients may sit in the ED for days and days before being admitted to the medical wards. The ED is essentially a ward in itself, one stopping point in this long and somewhat inefficient system of getting patients upstairs and eventually out of the hospital. The up and the out take quite a bit longer here than they do at home. No such thing as 11 am discharges here. And you thought our EDs were crowded.

We saw another patient in clinic the same day. This one was a 16 year old girl who delivered a baby 2 months ago.  She found out about her HIV, and hepatitis B, during the pregnancy.  Holding her baby, who quietly stared up at the ceiling, as if all was not right in his head, she sat at the desk alone, no parent or partner to help her answer our questions. She didn’t really seem to have a solid understanding of any of it and it’s unclear what care her baby was getting. She too was from the city of Buenaventura.  Having met both those patients in one day made me very sad for what that city seems to lack in health resources. Both of them would have access to regular medications and care here in Cali. 

Not in New Haven anymore, or am I?

The more time I spend in Cali, the more I realize how close it is to being at home, and the world feels just a little smaller. This point was particularly driven home this evening, as I sat in a large movie theater, in Chipichape, the biggest shopping mall in Colombia, wearing 3D glasses and watching George Clooney and Sandra Bullock stare down at the earth in the movie Gravity (Gravidad). It was a bit surreal leaving the movie theater after an hour and half of floating in outer space in 3D, to find myself in a large food court, in an even larger shopping mall, with thousands of Colombians walking from Tommy Hilfiger to Zara to the huge tank of plastic balls with jumping children. I forgot for a brief moment where I was. 

Earlier this week, I went to a teaching a session at the hospital, La Ventana Cardiaca (the cardiac window), a weekly tradition for the residents. Each week, cardiology cases are presented, in full Power Point fashion. In front of a packed lecture hall, an older cardiology attending, stops the presenters every few words, to bring out a teaching point or randomly call on people in the audience to answer a question. When he likes the answer, he’ll ask the whole room to clap, which they will in one resounding single, “CLAP!” If he doesn’t like your answer, there may be some teasing or joking. Later in the week, we had radiology rounds, also with the expected PowerPoint presentation to the attending, and the usual random questions directed at the residents (Contrast or non-contrast? Blood vessels or nodules?)  I even got my assignment for next week, to present on the radiographical findings of aspergilosis. Lots of Spanish radiology translation coming my way.

On Thursday evening, the Center for Infectious Diseases here in Cali held a meeting , which brought together adult and pediatric infectious disease specialists, to present interesting clinical cases.  Aside from the discussions about treatment of free-living amoeba infections, the hot topic of the night was…multi drug resistant bacteria and ICU acquired infectious with otherwise rare bacteria. They highlighted case reports from as far away as India and China with these specific infections. If I had the time I would actually love to do an epidemiological study of the infections and resistance patterns happening at Cali’s hospitals. The ICUs I’ve seen are impressively modern compared to what I was expecting, and although I see nurse’s wearing gowns, hats, gloves, masks, it does not seem quite as routine as at home. The rooms do not have those huge signs, “STOP. Gown and glove before entering this room!” I wonder if that makes the difference. I wonder if the prescribing practices of the ID attendings in this city matter more. How do you not use meropenem as your standard, first step, broad-spectrum antibiotic for sick patients in the ICU when you know that so many infections here are so resistant? We face similar questions at home.

Last night also felt like a very typical night of hanging out with other residents and yet, it was so much more exciting. Put a bunch of residents together anywhere, and the conversation will be the same: work schedules, difficult patient cases, fellowship and job applications. But last night, these conversations took place during the walk over to Tin Tin Deo, one of the best Salsa dancing clubs in Cali. Cali is particularly known for Salsa, and I think that every child is born knowing how to dance it like a pro. Walking into Tin Tin Deo felt timeless. Dimly lit, with hanging Chinese lanterns, black and white photos of great Salsa singers look down upon a large space, lines with small tables on the edges, and well-dressed couples dancing salsa in the middle. I’m sure it looked the same in 1950. The music is not live, but the energy is very real. Great salsa songs from the decades play continuously throughout the night. Each song has a very definite beginning and end. The dance floor clears after each dance.  Some people return immediately for the next dance, others take a break to sip some Club Colombia beer, or perhaps a shot of Aguardiente, a Colombian rum with an Ouzo-like flavor. I asked the residents, “do they teach this to you in school when you are kids?” No, they just know how to dance, and dance they do. The higher the heels on the high heeled shoes, the better they can dance. One particular woman, dressed in an elegant yet sexy red top which was low cut in the back, a short denim skirt, and 4 inch heels, danced beautifully for hours with multiple dance partners. The men were lining up to ask her to dance. I managed to dig up some basic steps I had learned years ago in Cambridge, at the weekend Salsa lessons and dancing, and was further helped by a Colombian dentist who came out with us that evening.  I probably did okay for a first night of salsa dancing in Cali, but I’ve a long way to go to 4-inch-heel chica.

Today I got to explore even more of Cali. After a grueling class at the gym this morning, which involved 30 minutes of spinning, and then another hour of a track style workout- outdoor running, sprinting and jumping up stairs on the edge of the mountain, I couldn’t possibly imagine moving again. But somehow, after a good Colombian power lunch, I got up the energy to spend the rest of the afternoon winding my way through artisan boutiques, the colonial streets of the San Antonio neighborhood, and its hidden courtyards. Every street in San Antonio is as first somewhat plain, old shuttered houses with solid wooden doors. But then you may come across a bohemian store selling jewelry and clothing made from recycled materials, or a vegetarian/vegan restaurant, or an art gallery. The most amazing home furnishing store I have ever been to was an unassuming corner house. But inside, a hidden garden and fish pond served as the centerpiece around which antique and modern tables, chests, lanterns and ottomans graced every corner of the house. I would live in that house if I could.

One more word before I close, on food. The people of Cali are quite proud of their traditional foods. I had the pleasure of trying some of these this week.
 

Cholado- Take all the tropical fruits you can think of, crush them up with ice, pile them into a glass with layers of fruit syrup and sweetened condensed milk, top with a wafer cookie. Sweet yet satisfying. Our resident happy hour on Thursday involved ten residents enjoying cholado at a street side café a 5 pm Cali traffic rushed passed. Pretty happy hour if I do say so myself.

Pandebono- Bread with cheese inside. How could you go wrong? Almost like a Bialy, only better. Every corner panedaria has them, and the smell of fresh, hot , baking pandebonos permeates the streets at all times of the day.  

 David knows how to enjoy his Cholado

 Fountain above a fish pond in the interior design store

 More hidden fountains and courtyards of San Antonio

 San Antonio street

Day one: scary bacteria, aggressive drug reps, and crazy gym class instructors

Day one. Infectious diseases consult service, los infectologos, as they say here. Although there are many infections here, there are not as many infectious disease specialists. And while Cali is blessed with many hospitals and medical schools, they don’t have enough specialists to go around. Each one is required to cover multiple hospitals, and they can’t always visit each hospital every day. My hospital, Hospital Universitario del Valle (HUV), was not lucky enough to have an ID attending present on Tuesday, or Wednesday as it turned out. The numerous consults awaiting him- the 19-year-old girl recovering from a severe pneumonia that put her in the ICU for one month, the man with pulmonary fibrosis waiting in the ED transitional unit for days to be admitted, the woman with the psoas abscess causing intermittent bacteremia, all had to keep waiting. In reality, none of them looked that sick to me. I think if things were different, and the outpatient milieu stronger, I think some of them would have already been discharged from the hospital. Unless their primary teams decide to proceed with plans or discharge patients without ID’s advice, the patients will probably keep waiting, until they are seen by all the requested consultants. They might be waiting a while.

Luckily, one of the other ID specialists was seeing patients at a different hospital, and we were able to join him. The backlog from the long weekend meant there were 13 patients to be seen on Tuesday morning, which made for a busy morning. Many of these are the standard problems we would see at home- diabetic foot infections, cellulitis, abscesses, pneumonia, sepsis. Some infections were slightly less common at home, like extra pulmonary TB or HIV with altered mental status.  Of course, there are always the questions of which antibiotics to use for slightly more resistant bacteria, or as sometimes the case here, very resistant bacteria. It is unclear how prescribing practices evolved quite the way they did here, but currently, they use some of the broadest spectrum antibiotics available (like meropenem) as the first line treatment for sicker patients, before cultures become available. They use meropenem the same way we use vanco and zosyn, which are usually quite sufficient. At home, sometimes we have to beg and plead with ID fellows and antibiotic pharmacists to get some of the antibiotics that they use every day here. That process usually annoys me, but I think now I’m more content with it. Yesterday, my very first day, I saw a pseudomonas isolate that was pan-resistant, and I mean resistant to everything. When asked what to treat the patient with, the ID attending chose three antibiotics (two of them quite strong) seemingly at random, hoping that together they would treat what each individual one could not.

Aside from the antibiotic use, much of what I’ve seen at the hospital seems very familiar. Although HUV is considered the public hospital, the not-as-nice hospital, I think it’s probably as nice as the nicest hospital in Rwanda. There are still open wards, but not as crowded, and with more private rooms. There are more nurses, more available medications and diagnostics (CT, MRI), more specialists, more computerized information. There’s even an electronic medical record! As of last week, HUV’s Emergency Department is entirely electronic. Want to check the ED note? Better go over to a computer.  Also very familiar are drug company reps. They are everywhere. They supply the residents with lunch almost every day of the week. After only one afternoon at HUV, I got myself a Lantus pen, an Amaryl notebook, free samples of an oral Factor Xa inhibitor (an anticoagulant) and just missed out on a pack of highlighters. Training a whole generation of doctors who are used to getting their drug information from the drug reps.  Guess the No Free Lunch organization (http://www.nofreelunch.org/index.htm) hasn’t made it down here yet. 

How better to top off my first day than joining the gym across the street? Somewhat reminiscent of my gym in Panama, it has that 1980s feel of muscular men and beautiful women using old weight equipment, looking at old posters on the walls of more muscular and beautiful people. The exercise class, run by one of those muscular men, involved lots of jumping, squatting and tension band pulling, with him yelling at us to keep going. I have to say, it kicked my ass. Today I am very tired. I’m going to call this Insanity, Cali Style. Let’s see what happens in 56 days.

First set of pictures...

https://plus.google.com/photos/106419429553511755451/albums/5934767487323835441

La vida en Cali, y Cartagena también

October 9th - October 14th

This trip is going to be different. Far away, but really not that far at all.  Flying a couple thousand miles south of New Haven hasn’t changed much in the way that I and many of my neighbors will be living our lives the next two months. Except it’s all in Spanish, and maybe it won’t be quite as cold.

Cali. Nestled into a valley between two mountain ranges. Watched over by a smaller version of the same Cristo Rey statue that watches over Rio de Janeiro. A snapshot of the morning commute would look a lot like it does at home. Commuters wait on the bus platform, waiting for the “Mio,” the local transportation system, to glide down its dedicated traffic lane, pick them up and carry them downtown. To skyscrapers, to their investment banking jobs, or maybe to a hospital. As they wait on the platform, bored, or multitasking, they scan their smartphones for new information, refreshing every few seconds. Rows and rows of compact yellow taxis whiz by. They pass by bakeries, and cafes, and little bodegas selling fruit and newspapers. Many have Halloween decorations up in the windows. There’s even a street of Christmas stores already open, glowing Christmas trees and waving Santas in the windows. I am told it’s cheaper to buy it all now than in December.  Give me a holler if you’d like some cheap Christmas goods. Cali’s main boulevards are not exactly pretty, but they’ve got everything you could need and the people are by far, the friendliest and most helpful I have ever met. Feel free to ask anybody walking on the street for directions, and they won’t just point, they might even show you themselves. 

Yesterday I experienced the artsy side of Cali. The national library was holding a Fernando Botero exhibit. Amazing how one person could produce so many paintings on the same topic (Jesus and the crucifixion) in such a short period of time (2010-2011). He did jazz up some of the pictures with modern clothing, self-cameos, and references to Central Park and the Statue of Liberty. We also visited the Museo de Arte Moderno La Tertulia and although small, contained some very cool pieces, all by Colombian artists. This was rounded out by enjoying lunch at an excellent hand-made pasta restaurant with heavenly pesto sauce, situated on a quiet little square near the museum. As we reveled in the culinary delights, a passing thunderstorm beat down upon our covered patio, sending the little park’s painters for cover. There was also a stroll along a riverside promenade, with an exhibit of pained cat sculptures reminiscent of the painted cow statues in New York City many years ago.  Finally, we saw Cali’s equivalent of the Big Dig, with some High Line mixed in. A lovely pedestrian walkway over a busy tunnel, with stylish wooden benches and tasteful landscaping. 

Today Nora and I, along with three of our housemates, a Peruvian surgery resident, a microbiologist, and a student, took a hike up the Cerro de las Tres Cruces. A mountain top to the west of Cali with three large crosses, looking down over the city. Locals tend to do this hike on Easter, but there were plenty of people hiking up today too, from four year old girls carrying ½ liter water bottles to muscular men running up shirtless. There’s even an outdoor gym area at the top, complete with dumbells made of concrete blocks and parallel bars. Our hard word was rewarded with fresh orange/carrot juice at the top. Cali is beautiful from above. 

Outside of Cali, the roads can get a bit rougher, so I am told. Due to the difficult and time consuming cross-country road travel, domestic air travel is a staple of efficient transportation here. Domestic flights leave full and often from all of the country’s major cities – Cali, Medellin, Bogota, Cartagena. Well-dressed businessmen check their watches, children play video games, women stroll gracefully in their high heeled wedge sandals up the aisles.  I know all of this because, even though I just got here on Wednesday, I took another flight on Thursday to the city of Cartagena. 

Jaime, our amazing host, a gastroenterologist, the attending who is in charge of us on this rotation, has already been treating my co-resident Nora to his family’s incredible hospitality and weekend adventures. It just so happened that my first weekend was the one they had chosen to take us to Cartagena, to stay in the luxury apartment that belongs to the hospital’s physicians’ association. If you want to play golf in Cartagena, this is the only apartment complex to do it. Picture three, six-story sleek white buildings, each with a picturesque and asymmetrical beautifully tiled swimming pool, beside a rolling hill golf course with lakes, beside the Caribbean Sea. Our art deco, wall to ceiling windows apartment, had ocean views and to the busy skyline of Cartagena beyond, similar to Miami and Panama City. The old city of Cartagena itself is a walled city, established in the 1500s, and has been growing ever since then. To me, it was reminiscent of Panama City’s Casco Viejo, with a smattering of Sevilla, Spain, Campo de Fiore, Rome and Essouira, Morocco. Narrow, cobblestone streets are lined with two story buildings, many with colonial style second floor balconies, dripping with greenery and flowers. Storefronts range from simple tiendas selling basic food items to trendy clothing boutiques, salons and gourmet gelato. Hidden plazas house fountains, churches and fancy restaurants with outdoor seating. Friday was also quite a day to be there, as Colombia defeated Chile in the World Cup qualifier. The streets were full of yellow shirted, horn blowing fans celebrating all night long.

Cartagena viejo is meant for strolling. Along the centuries old, fortress-like walls protecting the city from the ocean and foreign invasion, along the narrow streets, through the quiet plazas. I did not visit the new Cartagena, but very much like Panama City and South Beach in Miami, the ocean boulevards are lined with luxury apartment buildings and hotels, a home, or maybe just a weekend retreat, for wealthy Colombians. 

Back at our apartment, sitting in the pool, staring at the ocean, I reflected on the craziness of the past month, the many new opportunities that have just come into my life, and how fortunate I feel to be here. I could not have asked for a more relaxing and restorative weekend.

This was not quite the beginning to this medical rotation I had envisioned. The actual medicine has yet to begin. One brief breakfast orientation for the visiting students and residents, and meeting a smattering of South American residents is all I’ve gotten so far.  But tomorrow, I finally get to see another side of this city, and of life here. The surgery resident shared some stories of the severe trauma patients coming into the Emergency Room, losing massive amounts of blood from knife and gunshot wounds. He mentioned the shortage of central line kits for patients who needed pressors, and how they used neonatal nasogastric tubes to deliver the same thing. Nora shared with me the excessive use of inappropriate antibiotics here, everyone seems to get imipenems and linezolid the way we use ceftriaxone.

There’s going to be a lot to learn this month. Here we go.