John Jacob and John Isaac: an anecdotal hospital comparison

After an hour of being at the clinic, Dr. Nathan (see older post about this awesome doctor) was seeing a pair of 1 month-old twin brothers. Like a lot of twins, they were born prematurely and started life with “lung issues”. These two boys were born to a mother who lives far out in “el campo”, but she was luckily in Cusco this week for a training with her church to be a lay leader. Thus, on Wednesday when they initially came down with colds, they came to La Fuente. Dr. Nathan saw them on that day and was cautiously optimistic they’d be alright, but told the mom to return if they seemed worse to her. Two days later they seemed worse. At intake, John Isaac’s oxygen saturation level was 74% (normal is 94-100%, and at Cusco’s elevation it is 88-94%) So 74% means that his Red Blood Cells were carrying only ¾ the amount of oxygen that they have the potential to carry, and it means his brain, his heart, his kidneys, his hands, and his feet were only receiving ¾ of the amount of oxygen they need to receive. Plus, when you are sick, it’d be nice to have MORE oxygen than usual, not less. A quick physical exam confirmed that they were both really struggling to breathe (their noses were flaring and their bellies were retracting with each breathe). Think: the way you and I breathe after we finish exercising, except they were laying on the backs resting.

Needless to say, this was an emergency. I picked up the “less sick” twin John Jacob, and we called a taxi to come pick us up at the clinic. A nurse from the clinic (Nancy), the mom, me and the twins got in the taxi. We drove to the ER at the public regional hospital and my initial first impressions were actually quite positive. The building looked like a nice hospital and within 5 minutes we were talking to a triage nurse and maybe 10 minutes after that we were in a consult room with an actual pediatrician. (Impressively fast in comparison to what I’ve seen in the states).

However, this is where the “impressiveness” ceased. After an initial assessment by the pediatrician both kids were deemed to be worthy of hospital admission and a discussion of exactly how old they were began, as kids under 30 days go to the neonatology wing and kids over 30 go to the regular pediatrics area. These twins were 32 days old. Scarily, John Isaac’s oxygen saturation level was around 60-65 while in the pediatrics consult room in the ER. To all you none medical folk out there… if a baby is having trouble breathing, at baseline has lung problems and a machine is confirming that 1/3 of this child’s lung function is missing…would you think that maybe this child should be given supplemental oxygen? If you're wondering how long it took for this child to be given oxygen, the answer is atrociously too long: 4.5 HOURS!!!! 4.5 hours AFTER arriving at the hospital he was finally put on supplemental oxygen. In all honesty, I think if you wanted to make an argument to intubate the child and have a machine be breathing for him- you probably would have been justified.

At one point, I was looking at John Isaac and thought he literally might die while I was holding him in my arms. After hours of breathing at a level much lower than is normal, his extremities, face, belly and lips started to turn blue (a later sign of cyanosis). Also, his breathing rate (which should have been elevated above normal to try and compensate for his lack of oxygen) was actually lower than normal, another really scary sign that his body was tiring out from the increased work of breathing. I asked the doctors and nurses repeatedly when they were going to bring this child some oxygen? When are you going to start performing the 10 or so other orders the original pediatrician wrote for: lab tests, antibiotics, oxygen, etc. And I never could get a solid answer.

Another crazy/annoying thing about this hospital is that family members must take orders from the doctor and go to another part of the hospital to BUY supplies for the doctors/nurses. I understand the hospital doesn't have a lot of money and needs families to help pay for treatment, but as a baby is in an ER on the brink of death, this doesn't seem like the time when they should suddenly remember: “Oh, I need a piece of gauze before I draw this blood…Mom, go buy some!”. I counted 9 separate trips to buy various supplies and medicines during the 4 hrs we were in the ER. Maybe once, MAYBE once, I’d understand a pre-printed list of things the family needs to pay for before treatment commences, but not 9 times!!! And it is crazy to me that these supplies are not actually found in the ER treatment rooms themselves. Why waste precious time having someone go wait in line and buy these supplies? It was maddening, the inefficiency and dangers of this system.

True story. There was a tourist who had clearly had a bad night or some bad luck, as one quick glance revealed his hand was bloody. I heard him speaking in English that his money was back in his hotel, and they told him he’d need to leave, go get the money and return if he wanted basic bandaging or xray to see if it was broken. ARE YOU KIDDING ME!??!?!

In the end, both John Jacob and John Isaac were admitted to hospital beds and what seemed like a fairly competent staff of nurses and doctors assumed care of these boys. I haven’t heard anything yet, but I do believe they are going to be ok. But it is very scary to think of “what could have been”. The mom of these boys is very poor and surely could not have afforded to pay for the treatment they received in the PUBLIC hospital. Dr. Nathan, as we were pulling out in the taxi, handed Nancy the equivalent of 150 dollars. Also, we had “runners” who could go back and forth from the ER to the store to buy all the stuff the nurses/doctors kept forgetting to ask for. What if you are alone and sick- who can go and buy your supplies? Also, we had Nancy who was a godsend on two levels: 1) she speaks Quechua (local Incan language) and the mom didn’t speak much Spanish, so she would have not had any way to communicate with the staff at the hospital. 2) Nancy is a nurse and she understands the system. She was able to demand what we needed (it still took us awhile to get the oxygen). If just one of these things was missing: money, translator, runners, advocate, or if the family had been 8+ hrs from a hospital in their rural home….I honestly don’t think John Isaac would be alive right now, it was that serious of a situation. So in the end, I do believe God was working in this situation and the boys are going to live, more so in spite of the ER, not as much because of the ER.

Two other crazy things I saw in the ER: 1) There was wet blood on the floor in the middle of the hallway and during the 4 hours we were there, no one stopped to clean it. 2) There was a 1yr old girl in status epilepticus (seizures that last more than 15 minutes without stopping) and the pediatrician tried the first medicine you give for unceasing convulsions, this medicine didn’t stop the seizures, so they needed to move on to the second medicine. However, this required the doctor to write a prescription, then the mother had to leave her convulsing daughter and go wait in a line to purchase medicine number 2. Ten minutes later she returned with this medicine. With status epileptics, SECONDS are precious, as each moment the seizures do not stop, there is an increased risk for brain damage. The fact that there was a 10 minute delay between the second and third doses was infuriating for me. To me this that was a situation where you act as fast as possible, and then ask the family to pay for the medicine a few minutes later.

our "ambulance", aka a taxi

2-3 hrs after we arrived, some nurses started doing some things, finally

the mom and John Isaac, waiting at triage

the pediatric hospital wing, finally!

a little too close, but this is me and John Jacob waiting for the taxi

Dr. Nathan setting up the oxygen, in hindsight, i wish we sent the oxygen  with us to the hospital

John Isaac...waiting...waiting...waiting..

xray time

a pretty normal xray

time for a quiz!

-2 million people in the world have this disease, but today was the first time i ever saw someone with "active disease"

-medical history: cough for "a while", lost 12kg in the past 3 months, and he saw some blood in his cough this week, and thus he came to the city to see a doctor...he lives 10 hrs away in the jungle

-and you biggest hint...some xrays:

one note about the xrays: if you look the "L" side of the image doesnt show the heart shadow, but its simply mis-labeled and the R is actually the L side, we confirmed it wasnt a rare case of dextrocardia bc the gastric bubble is on the R, too, so that confirms its just mis-labeled...wanted to explain that, but dont get caught up on this detail, it was nothing to do with the case

I will post the answer (in case some doesnt get it right, in the comments section)

I will also post come extra comments about the case and some reflections about it, after yall have time to guess

A great day with a great Pediatrician

So, I know that writing 2x at once and then not writing again for a while (my habit with this blog) isn’t the best way to keep an audience, but we have sporadic internet access so I got to get them in, when I can…and after today’s work in the clinic, I really wanted to share with you a really exciting day I had.

A little background on the clinic I am at first: I have been working at La Fuente Health Clinic in Cusco for the past 2 weeks. It was a clinic started 10+ years ago by the Mennonite Church. The doctors we connected with via Dr. Mayes (my favorite/best professor from UR) are Mennonites and have been working at the clinic for the past 6 years. About 2 years ago, a team of 5 families came to Cusco to join in the work here at the clinic. 1 ophthalmologist, 1 pediatrician, 1 dentist, 1 pharmacist, 1 Nurse Practioner, 2 physical therapists and 1 physician assistant. They all went to the same Presbyterian church in Augusta, Georgia and all signed up to be a missions team together. Combined they have 15 kids under 10 yrs old, and their connection back in Augusta had been with a ministry called “Medical Campus Outreach”, where doctors/dentists reach out to med students. They came to Cusco with the goal of replicating this ministry with medical and dental students here in Cusco.

Ok….back to my awesome day…today was the first day I got to work with Dr. Nathan Wilson, the pediatrician from the Georgia team. I’d met him a lot of times, but working with him was one of the more inspiring days I’ve had in med school. I was equally challenged today to strive to excel academically in the practice of medicine as much as I was challenged to really love my patients and their families like God does. It is rare that these seemingly different (by no means opposite) roles of a doctor are so well exemplified in one person. I will try to elaborate on this…

-Today we saw a little boy named Saul, Saul is 4.5 yrs old, but is the height/weight of a 2 yr old, most of his specific health issues are related to the fact that he has Down’s Syndrome. Saul and his mom live in the one of the towns we visited with PROSIM (8 hrs away), they were able to get a free ride back with us on Sunday so that he could be seen by a doctor, and they came all the way to Cusco for a “check-up”. It was his first actual doctors visit in his life (despite the fact that he has a major medical condition!) We did a very thorough exam, as children with Downs are prone to tons of other health problems (congenital heart defects, thyroid issues, intestinal issues, failure to thrive, leukemia, early-onset Alzheimers)…but what Dr. Nathan spent even more time doing was encouraging Saul’s Mom. He shared with her a story from John 9, when Jesus is asked, “Who sinned, this man or his parents, that he was born blind?” and Jesus replies “neither..this happened so that the work of God might be displayed in his life”. Dr. Nathan told me that he spends a great deal of time talking to all parents with kids with severe disabilities because they need to know that the world promotes a lie, the lie is that their child is worthless. Instead, he tells them that their child, and whatever problem their child has (cerebral palsy, MR, downs, etc) is also a gift from God, and that their child and the way they care for that child is an opportunity to bring glory to God. I think here the idea that the parents must have done something wrong, and now they are punished with a child with Downs is very pervasive and this encouraging message can be life-changing for these families.

-Before we even saw Saul, I saw a 18 yr boy with the complaint of “abdominal pain”. Gastritis is extremely common here in Cusco and we diagnose 2-3 people with it every single day. I took the boys history (I worked up to 3 patient visits in Spanish today!) and came back to Dr. Nathan to present the patient to him. Over the past 2 years of medical school, the number 1 thing I've been graded for has been my ability to “present a patient”, no one expects the med student to know exactly what is wrong or to know exactly what meds/tests the person needs…but they do expect the med student to “present the patient well” so that the objective information is clearly communicated. When I went to present this boy with abdominal pain to Dr. Nathan I totally botched the entire thing. I was rushing, I was skipping around the presentation telling him random things “out of order”, and basically failing to follow the standard format of presenting a patient. Over the past 1.5 wks as I’ve been working with the other doctors here, no one has commented on my “sloppy presentations”, in fact, as Dr. Nathan later stated, “I've probably stooped to the level of organization/professionalism that has been expected of me”, but he said that he expects much more from me and will not accept a disorganized presentation. At first I felt embarrassed and dumb…(I know what to do, I know the right way to present), yet I was talking to him like a 2^nd yr student who doesn’t know any better! And in 2 months I am going to be a “doctor”! How could I be presenting so haphazardly? My gut reaction was to tell him I am good at presenting, I know what to do, but instead I resolved to do better next time, to prove to him (and myself, more) that I am capable to “talking/presenting” like a doctor. My next few patients were a bit better, but overall it was a very humbling “failure” and a good reminder to do my best even if I am only being asked to do “good enough”.

Finally, Dr. Nathan shared with me two “pearls of pediatrics”

1) “Continuity is a powerful tool”. He contrasted primary care with the emergency room, and reminded me that we can see the patient the next day if we are worried about sending them home. We can try something, and if it doesn’t get better, try something else in 2 weeks. We have the benefit of not having to waste money, or order extra tests, with the fear we’ll never see the patient again.

2) “Always listen to the parents”. He said that when a parents tells you there is really something wrong with their child, you need to believe them. They know that child a ton better than you do. He said almost every story he knows of a pediatrician being sued or a child dying unexpectedly/suddenly starts with the parent saying something is seriously wrong and an arrogant doctor saying everything’s fine. Not that it isn’t commonplace to calm worried parents by explaining the relatively benign nature of a viral infection…but that you should still trust a parents judgment when they are seriously concerned

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Now for 5 "old" pictures that should have been in the previous post about PROSIM, but these are more "health related" pictures so I split them up and put them here

This is what the nurse drives to work...about a 1 hr trip on a dirt road...hardcore!

This is the clinic/ health post in the small village...and in the picture is the ROCKSTAR public health nurse, Huana

I found this picture to be terrifying/awesome...its a vaccine schedule, but then they show these horrific pictures of kids with the diseases that could be prevented: measles, mumps, rubella, TB, diptheria, tetanus, etc...a bit gory for most moms, but maybe it works?

I just really liked this sign instructing women to eat 3 meals a day while pregnant. Isn't 3 meals standard always?

This is the view from the clinic, not a bad view from "work"

PROSIM: a public health trip to a rural mountain town

Hola! 

As you may have read about in Maren’s blog we spent 4 days last week in three little towns about 8 hrs from Cusco (and 7 hrs from a paved road). The family we are here working with is connected with the Mennonite church and the church has a really cool health outreach program called “PROSIM”. Basically, a public health nurse and whoever volunteers to go with her (us!) travel to one village every month for a year. The basics of the program are that they offer Health and Nutrition education to moms with children between 1-5 yrs old. Each month when the team comes they try to work with the same moms. There are even 2 “promoter moms” who do house visits in-between each monthly meeting to review the lesson and help moms implement the lessons. For example, if one week the teaching was on disinfecting fruits and veggies, they’d come around and reinforce that concept. Also, once a year a stool sample is collected from each kid and the most common parasites are determined at a Lab in Cusco. A month later, PROSIM returns with the proper de-worming meds for the most commonly found invaders and each kid is treated.

We were asked to go along on this month’s PROSIM trip and we are really glad we went. I will admit that by the time the 4 days were over, I was VERY ready to return to “normal/easy life” at our new home-stay. It was hard living and a very draining experience. But those feelings just reinforced the number one lesson I learned on the trip: The people who live in “el campo” are amazing. Their lives seem so difficult: their houses are made of mud, their kitchens barely have any light, there are little guinea pigs running around the kitchen, everywhere is dirty, they barely have enough money to eat anything other than potatoes, they go to the bathroom in holes out back and it just feels like they live so far away from everything! Anytime something was hard for me—It just increased my respect for them. For example when there were rats in our room making tons of noise all night preventing us from sleeping, I thought, this is someone’s house they have to sleep in every night.

As for the “public health” aspect of the trip I really respected a lot of what the PROSIM team has been set-up to do. A lot of what we saw first hand really connected to what I’ve studied and learned while completing my Masters of Public Health at Tulane. I even got to do a little teaching (IN SPANISH). I taught about the problem of childhood malnutrition, a huge problem in this area of Peru (35% of the kids are malnourished) mostly due to a lack of variety in their diets, not necessarily starvation (they get plenty of carbs/calories from their steady diet of rice, potatoes, bread and corn…the 4 basic groups of peru). Huana translated what I said into the local language of Quechua (the language of the Incans), only about 50% of the moms know Spanish. I based a lot of my teaching off of the UN’s guide to World Nutrition, and although there wasn’t anyone jumping to their feet for a standing ovation, I think I was able to reinforce what PROSIM has been teaching over the past year, and it was really fun for me to feel like I was actually doing public health.

Some of the “best practices” I saw being used first hand:

-In a society that learns mostly through oral story: Huana (the public health nurse) was reviewing a lesson about spreading infection and the importance of hand washing. Instead of telling the moms what to do, she used a doll to demonstrate the things a child does each day: Play outside and go to the bathroom. Then the child was playing with one of his friends and passed along some germs (he had not washed his hands), then the doll's friend got sick. She asked a few review questions about how this boy got sick and what could be done to prevent it. A cool way to “teach”.

-Empowering the 2 “mom-promoters” as community health workers to reinforce the lessons, plus they are known and trusted members of the community who can help expel commonly held myths about health.

-Also, this particular trip was a “transition” month, as we did a day of teaching in the community PROSIM has been visiting for the past year, but we also spent 2 days in the next community that PROSIM will start to meet with next month. In our two days, we were able to meet with the “president of the town” (a town of 200 families has a “president”), the doctor and nurse who work in the town, plus we got to present our program to a group of 20 people gathered in the community center building, and present to 50 people at the Mennonite church. I just really respect how intentional PROSIM was about making connections with all the leaders in the next town they want to serve

-PROSIM seems to follow a lot of the “Luke 10” model for service/missions work: they go out as a team (sent 2 by 2), they enter the community and look to connect with community leaders (‘person of peace’), they heal the sick, and they build relationships with people.

PS: It literally was the most beautiful place we’ve been in Peru so far…the mountains were just so drastic and it was so rural and scenic…couldn’t finish this post without adding that fact

if you look REALLY REALLY closely at the mountain on the other side of the valley, you can see there are 24 switchbacks going up that mountain...CRAZY!

paulie the parrot!

This is someone's kitchen and dining room. There is only one light, so without the flash on my camera, it would have been impossible to see in here...there were also 15 guinea pigs running around the floor as we ate.

Presenting PROSIM to the next community we want to work in.

This was a "big moment". The guy with the baseball cap is the local doctor and guy with the white hat is the "assistant president"...both agreed to have PROSIM come next year.

Another local doctor teaching LACTATION to some moms (notice the white baby doll for teaching)

CARMEN...the 10 yr old daughter of our driver. It was awesome to have her on this trip, she was really excited about everything, and led me to the conclusion that most things in life are more fun with a child around, they are just so happy.

Carmen and her dad, Gregorio

PSS: I read “The Road” by Cormac CcCarthy on the drive to/from. I liked it and it was a page-turner, but I was wondering if any of yall, perhaps those a little more creative and insightful, might be able to share with me some of their thoughts about the book. I am smart enough to realize it was a really “deep book”, but not smart enough to actually connect all the dots and figure out all of the meaning…this deficiency of mine is the reason I don’t get much out of poetry when I read it, but I love hearing a poem dissected and explained for me.

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here is the link for MORE PICTURES!!! (sadly when i made this post only 40/100 were loaded so i had a very limited selection for my post, which i wanted to get online tonight, but hopefully soon i can get the rest on picasa)

more pictures, click here!!!

first day at the clinic: great success

Yesterday was my first day at La Fuente Health Clinic. It was a good day, to be my “first day” because both the Family Med doctor and the Pediatrician that we’re being hosted by were working. This meant who ever had the more interesting patient, I got to join them, and it wound up being a really fast-paced and interesting day.

Here is a list of the patients we saw: 40F with a lip wound for 5 yrs. 13F with stomach pain, weight loss, headaches, plus we diagnosed her with mild scoliosis. 5M with a cold and possible bacterial diarrhea. 4M with a cold. 22F with headaches. 2mo baby boy for general check-up. 27F with headaches. 62F with pelvic pain. 33F with a sore throat and chronic stomach issues.

The list isn’t that crazy…besides the first lady with the unhealed lip wound for the past 5 yrs, it’s a list of very common complaints both here and in the states. This being said, these visits were nothing like the doctors visits I am used to in the states. The way you diagnose things here, the “home remedies” people have tried, the medicines were going to prescribe…it is a bit different, even with such “routine issues”.

For example, the 22F with headaches, shes never had her vision checked…ever! (how could this be!) the doctor I was working with quickly figured this out and is highly suspicious this is the source of her headaches.

OR for example, for the 5M with diarrhea, the pediatrician I worked with said that she’d never give antibiotics for diarrhea right off the bat, first of all diarrhea is almost always viral in the states, plus she feels confident in getting tests on stool samples in the states. But here, the family we saw wasn’t going to have the money to pay for a stool test that costs less than 15 dollars, and there is a higher likelihood its bacterial.

And the most glaring example of “whats different”: ALL THE PATIENTS SPEAK SPANISH! Despite being immersed here for the past two months, and practicing “medical Spanish” at my Spanish school for the past 3 wks…the first few patient visits were really difficult to follow. Lots of our patients speak Qeuchua (the native INCA language) as their first language, and Spanish as their second language, so that adds to the difficulties, but by the time the day was over, I was figuring out “most” of what the doctor and patient we talking about.

Also, cool news: I even mustered up the courage to see a patient on my own…my very first Spanish patient encounter without a translator, ever! In all honesty, I sorta butchered the encounter, I had to read a few questions to her, but for the most part I knew her basic medical history and what her current complaint was…and when we went back into the room with the doctor he said that there wasn’t much that I missd.  At one point, wasn’t able to pronounce the 2 words I know that have to deal with “going no. 2” well enough for her to understand me and I restored to pointing at my backside to try to get her to understand me…a very funny moment for me.

Anyways, it was a very satisfying first day, its increased my desire to really practice my Spanish out-loud, with the hopes of being able to do more and more patient visits, on my own.

One other cool thing, the doctor that I work with overseas a public health outreach program in rural towns, 8 hrs from cusco…they mostly do nutrition programs as well as basic health education…And: maren and I are going to go on one of these 4 day trips, this week. I will have to miss 2 days of clinic, but I am really looking forward to this chance to “see public health in action” after 4 yrs of studying it, plus, I am going to get to give a lesson on “malnutrition”, which is a huge problem in this area (44% of kids under 5 are malnourished).

Alrighty, like I said, some of my posts are going to be a little more medically related, hope to still keep your interest, by continuing to share stories and pictures as well.

a picture of the clinic where I will be for the next 2 months

Welcome to benjamin's blog 2.0!

My blog is officially “changing”…new title, new focus.

Why the change? Starting tomorrow, I need to “keep up” with this blog for another purpose: to receive credit for my “International Family Medicine Rotation”. I’ll still post fun pictures and ramble about my life, but inter-mixed will be posts specifically related to what I learn/see in the clinic.

So we’ve officially crossed the “half-way” point of our time in Peru, as we finished our time in language school and are now moving on to the volunteering portion of our trip: maren at Promesa (a bilingual Christian school) and me at La Fuente (medical clinic).

After taking time to reflect, I have a random list of things I feel that I’ve learned so far (warning: this is an incomplete list, but i do thing it captures a God bit of the things on my mind after these first 2 months)

-Travelling abroad with Maren is really wonderful, I do have a tendency to enjoy “random wandering around/poking into shops” more than she does (a trait I most assuredly got from my mom/auntie linda), but for the most part we love doing the same stuff and we love doing it together

-I have learned 1000s of Spanish words, but when I am in a conversation with someone, I use maybe 10% of them, there is a big difference between “knowing” a word and being able to spontaneously use it

-Going into this trip, I would have thought that I’d be ok in any sort of home-stay, as I realized that people live very differently than I do, and I realized people have a lot less than I do in the world. But, now I would say I “have limits” when it comes to cleanliness and courteousness. This isn’t to say first home-stay was a negative experience, the family was very welcoming, but lets just say I was very ready to be moving (as a side note: after only 1 day at the new home-stay, I am thrilled to report that it is an amazing situation, the family is incredibly generous and friendly, very patient with our Spanish, plus they the Father is the president of a local pastors association and the mom works at Promesa as “the cook”…so the food is amazing at their house and despite our language barrier, I’ve already come to respect Roberto as a really solid guy, plus their 35-yo-ish daughter is really cool too!

-God is faithful, and he loves us. I guess I should have put this first, but this is more of a “Stream of consciousness” than a ranking, but this has been a big theme of the past two months. Gods faithfulness, a “theme” that I first realized during a Sunday sermon one week, but its something I can attest to in many areas of life here. We’ve been reading through psalms and Isaiah each morning, and I’ve been struck with how many promises God makes to his people, especially promises to save them or protect them or destroy their enemies or make their paths straight, etc…

-I think wayyyy toooo much about the future, this has always been a problem for me, but with residency starting in just a few months, the hours/the lack of time off/ planning for the future…its become a bit too consuming and sadly taken away from my ability to enjoy/embrace the present

-Having deep conversation with non-Christians is really important. I typically am fearful in these situation and just content to listen, but the discussions at the meeting place (see older post for more info on the meeting place) have really been amazing, especially for me, I cherish/need to hear other people’s view points, it challenges me and keeps me thinking. I never want to be complacent with my beliefs

-I think I came here with too high of expectations, but one of the big reasons I wanted to spend 4 months in Peru was to learn what its like to be an American missionary here. Despite meeting lots of missionary families, and even having the opportunity to share with them this expressed desire of ours, no one has reached out to us or tried to pour into us. Now I understand we are only here for a short time and that these people have real lives and real ministries to spend their time with, so I think most of this is faulty-expectations with a little bit of self-centeredness, but still, I do hope these next few months afford us the chance to get to know some of the long term people here, better.

-I’ve also learned that being a missionary doesn’t mean you have to live an uber-simple radical life without any comforts or privileges, to my surprise, most of the missionaries we’ve met have really nice houses that are pretty and spacious, and I do think this adds to their ability to “not burn out” and instead have a little bit more of a “normal life” abroad.

-I can actually enjoy a “simple life”, in the states my life has always been very “full”. Lots of stuff to do, not enough time to do it all. But here, life is refreshingly simple, we have time to sleep (8+hrs every night), read, watch movies, be spontaneous, etc…its rather wonderful, even though I cant imagine not going back to my “normal busy self” upon returning

-We can handle high altitudes and rain! We’ve been living at 13,000 ft for the past 2 months, and for the most part feel “acclimated” now. And its been rainy season ever since we got here, and it hasn’t stopped us from loving life, so I think we’ll be able to handle Seattle’s rain (I hope).

-I love singing worship songs in Spanish, it has probably been the most “fulfilling/worthwhile” part of spending all this time studying Spanish, as I generally understand 90% of what I we are singing, and it is really fun to be “using” the language, not just studying it

-When living away from “friends” (as in not having face-to-face friends in my midst)…an email, a text/voice message, making time to skype…all of these things are a huge blessing. At times, other than my beautiful wife, it’s the only “relational stimulation” I receive, and it means a lot

A whole post, just of pictures...

these pics are a few weeks old, but they are still pretty and we havent taken any cool trips since this trip to the COLCA CANYON, so i feel ok posting them now

notice my feet, and the view...from our hotel's porch, we loved this hotel (naturally)

the hotel stay, included a complementary 3-hr guided hike through the valley, maren and  I were able to butcher our way through a 3-hr spanish conversation with him, he was a saint

this llama literally spit in my face, about 20 seconds after this picture (GROSS!)

charming dining room at the hotel

I am not catholic, but i dont quite understand the whole idea of churches seeming to be museums first and churches secondarily, intersante

yup...maren paid this kid money to take a picture with him

notice the white-capped mnt in the background

lush

look REALLY hard, and you can see an ANDEAN condor, they have 3meter (10ft wing-spans)

At "ciudad de dios", a poorer neighborhood in the city of Arequipa...we got to tag along with a group from El Camino church, as their members spend every sunday after reaching out to people in this community 

Pastor Craig Querfeld, a missionary in Arequipa, who is partially supported by my parent's home church in philly, really amazing guy, got to spend some quality time with him and his family