The difference between the ICU and the medicine wards is sort of like the difference between making a microwave dinner and preparing a five course meal from scratch. What became painfully obvious to me the first day on the ICU is that I’ve gotten really good and pushing the buttons on the microwave, yet I’ve never had a cooking class a day in my life.

I can think of a few days in medical school maybe even intern year that I felt a little overwhelmed, but I knew without hesitation that my first day on the ICU was the most overwhelmed I’ve probably ever felt. The patients are so sick that any one of the 10 problems each of them have would easily qualify for a ward admission. The hardest part however is trying to decipher the maze of wires and tubing running out of every orifice plugged into a variety of machines and pumps that are apparently doing something good for them. There are drugs that I’ve never heard of, or have never used. You don’t exactly treat septic shock with a Z-pack.

Somewhere in the middle of one of my first presentations while stumbling through ventilator settings my attending sensing my stress hormones rising responded “don’t worry you’ll get the hang of it, but your gonna get fire hosed this whole first week”. Fire hosing was a new term in my lexicon, and I instantly wasn’t very fond of it! The bombardment of foreign drugs, machines and pressure volume curves made me feel like I was working in some kind of bio-physics lab than a hospital, it did however make me question if I actually went to medical school.

At the same time I was eating lunch that first day there was an elderly gentleman that was leaving the allergy clinic, as he got in his car to leave the hospital he started getting short of breath. A passerby noticed this and continued to watch as he stopped breathing and slumped over in his driver seat. As he was rushed back into the hospital by EMS who were pumping away at his chest and intubating his lungs the MICU pager quietly vibrated. My resident who was doing five things at once asked if I would go down to the trauma bay and just write the venitator/sedation orders to get the guy upstairs. As I walked into the trauma bay the ED team looked at me with relief that the MICU team was to the rescue. Needless to say I had no clue what the hell I was doing, the imitator exposed I kept thinking. Thankfully my upper level came down to check on me (aka rescue me) and the crisis was averted. I’m sure that as the month goes on I’ll get better at this, but for now it was a bit much. We got this guy upstairs and it was clear there wasn’t much hope. The family eventually withdrew care and let him pass. The black cloud of the month had begun.

 Is the answer to the question what I will be when I grow up! Besides last month the last few months haven’t been all that bad. I was on Neuro for a month and then GI, my role was somewhere along the lines of a med student with the ability to write prescriptions. I got weekends off, and for the most part was home well before 5pm. Nothing to complain about at all, in fact I was starting to slip away from the reality that intern year is supposed to be hard.

The slap back to reality came last month when I started on the CCU service, other known as Cardiac critical care, other known as the soul crusher. I wrote a post a few months ago where I over exaggerated a mythical intern being physically beaten with charts. It wasn’t until I started the CCU that I felt that post was actually gaining legitimacy instead of absurdity. I apologize ahead of time if there are typos in this post, its because just thinking of last month is going to make me vomit on my keyboard.

So just to get the basics down, the CCU is the admitting service for cardiology. We admit patients to the ward, or the ICU. We admit everyday. If the rotation of Pluto is at 72 degrees above the horizon there is a chance that all the days work can be wrapped up by 4:30 and all of our patients can be signed out to whoever is on call for the night. There are two interns on the CCU and three on the regular ICU, we all rotate call (that whole 30 hour thing). Call was such a nightmare I’m devoting a separate post for it. As you may have guessed it was pretty rare to sign out before 8pm. The only issue with this is that in order to see all my patients in the morning I was getting in around 4am, sometimes earlier. Its not hard to see how you can be pretty screwed if your getting out at 9pm and then are on call the next day going on about 4 hours of sleep. The thing is I have no place to bitch about a Q 5 day call schedule, as my surgery friends can testify that it would be a vacation compared to Q3. Actually working almost triple the hours what the average American works wasn’t even the worst part. The worst part was working with bitter, aggressive, tormented, and all together angry people that redefine passive aggressiveness. This in combination with a breakdown of communication at almost every conceivable level is the perfect formula for Intern hell. There are two fellows that basically run the service, two senior residents below them and of course two interns. The fellows run around all day long tending to the patients and performing mysterious procedures that ultimately get transmitted to the team, by either illegible notes, or I guess telepathy. And who is ultimately responsible for tending to these microdetails, on a service that will admit three patients and discharge them the same day, you guessed it.

Basically the team moved so fast, and with so much misscomunication I had to pretty much revamp the way I did everything. The issue with that is that after doing a few months on the medicine wards, not to mention two years in med school I felt pretty good about my system of organization, so the fact that one month could basically make me feel like a new third year med student again is pretty impressive. Just as an example, when we rounded on the patients I would often get scutted out to go make some phone call and miss some key thing that the attending said and of course later get yelled at about it later. To counter this I started bringing a recorder on rounds and would tape entire presentations, and listen to the things I missed after rounds. Its sounds over the top, but it turned out to be a lifesaver more than once.

On my last day I remember walking outside and the sun hitting my face, having not felt it in over a week in conjunction with being done with the nightmare I think it was the happiest I have been all year!

If the CCU wasn’t bad enough the way call was set up was down right dangerous, and everyone knew it. If I only to admit CCU patients all night and tend to existing patients it would be more than manageable. The issue was I also had to oversee the existing ICU patients and admit to the ICU all night as well. The ICU patients were ridiculously complicated. When the nurses called me about some really sick patient I had never met all I had to go on was a couple lines that were signed out to me from the other interns about that patient. For several of the calls the ICU was almost full, and the ICU pager did not stop going off, thankfully I wasn’t alone there was one other senior resident on call with me. I typically called them for just about everything. I could deal with a patient having a headache in the middle of the night on medicine, I couldn’t handle a patient whose blood pressure was 70/30 maxed out on a vasopressor drip and a failing heart, while my only piece of information I had was a little sheet that read “may become hypotensive”.

The other edge of the sword was that the ER could hit us with a train wreck at any given time. So the ingredients of multiple patients doing poorly on the floor, and new patients trying to die in the ER, and only two very sleep deprived new doctors to save the night from collapsing is a recipe for disaster. Thankfully this mixture never quite lined up, a disaster would present and would be managed before the next one, it always seemed like we narrowly dodged catastrophe, yet the threat was always felt.

There are of course a slew of shit show stories I could tell from call last month. My favorite, or maybe least favorite happened my last night on call. The night was actually going pretty steady, no major issues. We had admitted one patient and I was in the ICU finalizing some things in the chart. Meanwhile my senior resident was down in the ED seeing a new one. Naturally I was figuring he would call me when he needed me, as he told me to stay up in the ICU if possible. Some time went by and all four of my pagers were quiet, which is an uncomfortable feeling. In the corner of the room I overheard someone say that their pager wasn’t working. I quickly put it all together and paged all of my pagers, none of them went off. I walked around inquiring about the pagers, it turned out the entire pager system was down. This also meant the code pagers were down. I walked around and checked on my patients, after all if something was wrong the nurses would have no way of reaching anyone. As I strolled around telling nurses and other doctors about the situation, It became quickly apparent that everyone had a pretty laissez attitude about it. I guess its important to appreciate that in the middle of the night doctors and respiratory therapists are few and usually very far between. After I checked on my patients and I had this gloom come over me that some disaster was taking place several floors away at some nursing station tucked away in some corner. So to make myself feel better that the world wasn’t crashing in on its self I basically went to every nursing station in the hospital and made sure everything was ok and I gave out my cell phone in case something happened. Not that I could really do anything if something happened, but at least I could maybe triage and find the people that did know. At one point I went down to the ED to see how my senior was coming along and let the ED know about the pagers, again I was met with a who cares type attitude that I was having trouble believing.

After walking/jogging around the hospital again the pagers started working and I went back to tend to the ICU. The whole thing only lasted about 2 hours, and thankfully nothing bad happened. But it easily could have. I was never looking for recognition or gratitude for what I was doing. I actually just wanted someone to help me, or at least give me a better idea of how to manage the situation and no one gave a shit! It was unfucking real! In fact just to twist the knife a little deeper when I finally came back to the ICU one of the nurses said in a sarcastic voice “oh look here comes the hero” while rolling her eyes. I’m pretty sure I snapped my pen in half.

My pager is a nagging vibrating box during the day. In the middle of the night however it grows fangs and threatens to eviscerate me if the will of the hospital so commands it.

Call days on medicine start at 6am and go until noon the next day. From 7am to 8pm we admit whoever the ER feels like dumping on us. This is usually mundane work of writing orders and the typical hospital run around that so many of us got used to as med students. After 8pm however we stop admitting, the upper level resident goes home and the two interns are left to deal with “cross cover”. Basically all the other teams sign their patients out to me, I get a little spread sheet for each patient admitted to either medicine, neuro, or oncology that tells basic info about why they are there, meds, things pending, etc. That’s when the pager starts. I think if there was any point to paying attention in med school it should be because of the hours of 8pm and about 6am while on call. The nurses call me about anything and everything most of the night on patients I have limited information about. Some of these calls are outright hilarious, some are terrifying. I am supposed to only get called about patients that have been signed out to me, or that I am cross covering. But sometimes a rouge nurse won’t know who to call and just start going down the pager list. Here is a short list of some of the more ridiculous things I’ve been paged with.

Nurse: “so I know your not covering this patient, its a dental patient, and they just wrote an order for percoset without a dose or a frequency. What do you want to do?”
Me: “nothing, call the idiot doctor who wrote it.”

Ortho resident: “Hey man, your on call for medicine right?”
Me: “Ya, whats up?”
Ortho: “well I got this guy here that just needs to be discharged, its a medicine patient, but we operated on him, and there really isnt any more issues”
Me: “This isn’t a cross cover issue, the primary team can address it tomorrow”
Ortho: “Bro, Bro, listen someone just needs to come down here and send this guy home.”
Me: hanging up the phone.

Nurse: (multiply this call by about 20 over the course of the month) “Uh, ya patient so and so is having trouble sleeping.”
Me: “So am I, tell them its a hospital.”

And some of the scarier calls….

Nurse: “Patient so and so is doing weird things on telemetry, and breathing funny.”

Nurse: “ Um, I’m really sorry doctor, but I accidentally gave the a patient his neighbor’s medication”.

Nurse: “Patient is ripping IV’s out, screaming, and saying she is leaving”.

Then of course there is the random assortment of fevers, chest pains, headaches, vomiting, and whatever else the body can do in the middle of the night that would only confuse me. Of course there is another resident in the hospital that is there to back me up if I need it, but its kind of poor form to call about every little thing. I only called her twice in the month. Once about a guy in respiratory distress, and when the nurse decided that a patient with hypertension and kidney failure should get his neighbors steroid bolus. The rest of the time I am expected to be the authority on all kinds of nonsense. Its cool in way because its one of the few times I’m actually counted on to be a doctor without any back up, but it can also be annoying, and scary as shit.

I won this award today! Thanks to anyone who nominated me!? According to the website http://blogofthedayawards.blogspot.com/ receiving this award will bring fame and notary beyond my wildest imaginings.. I don’t feel anything yet…wait!…..no, that was just gas.

           There is a question that every patient gets asked when they are admitted to a hospital. It can be easy, or awkward depending on the delivery. Its called a code status. Basically we have to ask them if they would like to survive this experience. I don’t remember any interns or residents asking this when I was in med school, although I’m sure they did which means its was probably so short and sweet that I never caught it. The resident I’m working with now likes to add to the long list of his social handicaps by waiting until the end of his interview to ask the question, and it usually goes something like this. “ Now mam/sir, this is a difficult question, and something we have to ask. If your heart were to stop beating, would you want us to shock you with paddles?” At this point there is sometimes a pause, and the patient tends to look up with wide eyes that scream, What! I’m here because I’m dehydrated! Are you saying my heart is going to stop? Dear God! They usually say something like, “umm, well, I don’t know. Is that going to happen? Well I guess its ok.” Or they say, “no, no that sounds terrible”. At which point I typically jump in and say something like “we would only do it if it meant saving your life, and its only policy that we ask, if I came to the hospital they would ask me the same question”. Once that is clarified it tends to go a bit smoother. Then he goes on by saying, “now if you were for some reason to stop breathing would you want us to stick a tube down your throat and breath for you”? Again, the same look and interaction typically take place.

          One night Mrs. M, and old confused lady came to visit us. She needed to be admitted basically for observation. Internal medicine is more often than not a glorified baby sitting service. When the awkward question came up, thankfully the family was there to clarify that their grandmother did not want to be resuscitated. This meant she got the rubber stamp of DNR/DNI on her chart, (do not resuscitate, don not intubate). A few hours later the nurses called me saying that Mrs. M does not have a DNR/DNI form filled out. Having no idea what they were talking about, which is usually the case when the nurses call me, I went upstairs to fill it out. The form was about 20 lines each asking a specific question with a box to check yes or no, the questions ranged from “Do you want us to shock your heart with paddles?” to “Do you want us to use oxygen if necessary?”. I only understood the real stupidity of the form when I was reading it off to the family. It turns out the family said that her heart was to be resuscitated if necessary, but she did not want to be intubated. I noted it accordingly and put it in the chart. I find out later from my resident that only staff can fill out those forms, interns and residents are not allowed, and of course there is no attending on the planet that is going to come in during the middle of the night to accurately access someone’s code status. “So… then what happens” I ask, my resident replies “she is full code until the morning, when the staff comes in, if she croaks tonight we have to do everything regardless of what her wishes are”. Just another fine example of military medicine bureaucracy.

        That morning when I gave my presentation on her to staff, I mentioned that she was DNR, but not DNI. The staff doctor throws her hands in the air saying. “So what I can shock her, but I can’t stick a tube down her throat? She isn’t ordering off a Chinese menu! This isn’t McDonalds, you can’t get a large resuscitation, but please hold the intubation”. I’m glad she said it because I was thinking it all night, I mean that form was ridiculous, in theory someone could select yes to intubation, but no to oxygen therapy. That would be like going to Starbucks and ordering a coffee, and not wanting a cup to put it in.

        After a little over a week of night float I’m thankful to report that the first night was by far the worst night. The work load is really hit or miss, and I think it depends who is staffing the ER. Some attendings are seasoned walls and can feel comfortable managing a wide variety of things, and will let very few cases slip by and be admitted to the hospital. While others are sieves that tend to let the simplest of complaints warrant an overnight stay. The two major problems I’m starting to see at least at this military hospital is that a lot of staff are pretty young leading to less seasoned staff running the ER, which means more things slip through to get admitted. Second, there are no observation beds in the ER. Other hospitals tend to have a 24 hour observation section off the side of the ER for lower acuity patients. Not here, so again more patients need to be admitted. So in short, some nights the ER might be full and we won’t get a single call, other nights it may not seem that busy, but we are somehow admitting all night long.

         One thing I am surprised about is the diversity of the patients. Before I started I thought this year would be pretty boring, I was thinking a military population wouldn’t really get sick. Turns out that I have been seeing a lot of the same things I would see in any other major city. The reason being is that its not just active duty that come to the ER. Veterans, retirees, spouses, and children all get access to our gates. Granted its not quite New Orleans, we don’t tend to see the sweet old grandmas that upon further questioning enjoy their bump of cocaine before bed, and I tend to get funny looks when asking senior citizens about what kind of street drugs they use. The other thing I enjoy is that in the middle of the night not only medicine can admit, but neuro, surgery, and heme/onc all have their own call teams. There is even a chest pain service, so in theory I don’t have to be up all night doing acute coronary syndrome rule outs, which was the vain of my existence at Tulane.

          I’ve gotten a little more used to the flow, and the schedule of being nocturnal, which I really am now. For example I have a couple days off so yesterday I stayed up until 10am went to bed and woke up at 7pm. Now I’m sitting in IHOP because its the best thing san antonio can offer in the middle of the night. But I have to say, being at IHOP on a Saturday night at 3am completely sober is pretty entertaining.

        One thing that is coming into focus about this year is that there really is no room for error. I’m not talking about patient management, there is plenty of room for error with that. I mean day to day life. This came to light a few days ago as I started to get sick, probably nothing given the amount of viral stuff floating around. But, the thought occurred to me, what if I actually needed to go see someone, and then what if I needed to see a specialist after that. In the military it seems you have to go through all the channels, getting your buddy to write you something is frowned upon. Right now I get home from work around 10am and wake up around 5pm, and even though my hours will change my availability during the day won’t. My resident agreed that this is one of the hardest aspects of residency, he was telling me how he could barely get to the dentist during his intern year. God for bid the engine in my car falls apart or something. But my life is fairly simple. I’m not sure how having a wife and three kids works during this year, and I know plenty of people in that situation. Basically whenever I feel crunched for time I just think of how hard it must be for them. My other new found pleasure in putting my own life into perspective is driving over to the basic training side of base and seeing the new wide eyed 19 year old basic trainees get yelled at. I fell into this by mistake the other day when I went over to the finance department. There was about 40 new BMTs (basic military trainiees) lined up outside, they had just got off the bus and all of them were still wearing civilian clothes. Weaving amongst the flock were about 4 drill instructors. There was a lot of nonspecific yelling as I walked by. Some of things I caught were “You piece of shit! Look at you, your a fucking disaster”, or “I should choke you out right now”. The best part was when I walked by the drill instructors they had to stop what they were doing to salute me and say “good morning sir”. So as tough as this year can be, at least I’m not a BMT. Hey that kind of rhymes, might be a good slogan.

“What is that?”. “I’m not sure. Whats that smell?”. “I think, ya, that’s fear alright”. “poke it with something would ya, I’m a little worried”. As the two senior attendings examine the body quivering underneath the desk it slowly turns toward them and peers back with swollen, sunken beety red eyes. Only a few months ago these same eyes carried a sheen that could captivate the hearts of his friends and speak only the most heartfelt optimism to total strangers. Now when these eyes glance at people on the street they tend to walk the other way. For eyes like this could only mean that this person intends to either kill, or has been on a meth binge for the last week. In fact the only people that find interest in these once human eyes are the police.

“Hey its turning over”. “Wait a second,. Jesus Christ! Its an Intern”. “The intern mumbles something that sounds like a phrase somewhere between “feed me”, “help”, “sleep”, or “no more”. The attendings in a unison barrel rolling laugh silence this quivering by grabbing the nearest stack of charts and beating the now feeble minded fool with them. Once the intern is back in his chair they place the blood stained charts in front of him, and bark “Get back to work! And if anyone asks you haven’t been here longer than 80 hours you piece of shit”.

Thankfully I have not yet become the person I describe above. To become something is a journey, a quest, it is a road that first must be traveled. In this so called road trip, the shell of a man I describe above is the destination. I have only just pulled out of the driveway with a full tank of gas and a body full of energy and excitement. Why do I have enthusiasm about the start of such a treacherous path that will inevitably only lead to self destruction? I have no idea.!! Apparently somewhere deep in my subconscious, somewhere between MCAT, USMLE, NRMP and other acronyms that really only spell pain I must have come to accept suffering as part of my being. I mean before diving into what will hopefully be entertaining accounts of intern year lets put a couple things into perspective. For the last decade I’ve gone to school accumulated a theoretical debt of over a quarter of a million dollars( no I don’t have that much debt, I decided I would rather be shot at), sacrificed years of my social and sexual prime in trade for a nice cup of coffee and seven gazzilion hours in a book. Finally in one glorious day a silky hood is placed on me, hands are shaken, congratulations given, and the MD is branded. What is the reward for this? What is the instant gratification? The privilege of working at least 80 hours a week for the next X number of years and making a fraction of minimum wage! All while being knee deep in a malignant egocentric culture that would have any fortune 500 companies human resource department in an uproar. What I would like to do is sit any over achieving 18 year old down that wants to be a doctor and tell them these things. If they still want to go through with it after all that they are either insane, masochistic, or overly idealistic. All of course being values I would admire in anyone!

So lets start out with the question of happens in the hospital in the middle of the night? When all the patients are tucked away and visitors have gone, what then? Could it be that like some Stephen King movie, the doors start to creak open and all creatures of imagination lurch into empty hallways to wreck havoc on whoever falls into their path. Then in a burst of white brilliant light a doctor in a white coat shows up on a white horse sword glimmering overhead to slay to beasts of the night. Well I would soon find out, because my first responsible act as Capt MD was the feared two weeks of intern year known as Night Float.

The set up in this military hospital is like so. During the day there is an internal medicine team that is “on call”. Until 8pm any patients that need to be admitted to a medicine team from the ER are taken up by this team. After 8pm the call team stops taking patients, everyone from the team goes home, but two scared and weary intens stay behind to manage any problems that may arise from any of the existing patients in the hospital. These Hydra slayers where the title of “cross cover”. Also at 8pm an Intern and a second year resident come in to make up the tag team known as night float. Night float basically admits any patients that come into the ER that need to be on a medicine team from 8pm to 7am. So the job of the night float intern, aka “me” is to work with this resident admitting whatever the ER wants to let slip by and make sure they survive the night, in the morning I wrap these patients up like a nice little present and hand them off to another team.

After a few days of trying to beat my circadian rhythm into doing something it clearly does not want to I was ready. As far as first nights go, it probably couldn’t have gone anymore story book wrong. I naturally couldn’t find anything, I some how didn’t have computer access even after doing days worth of training and computer inprocessing. This was of course typical for the military, when I explained my frustration about it the next day I was met with a smile that said “your new to the military, aren’t you?”. Right from the start the night was alive. Two patients were waiting in the ER. My resident thankfully knew his way around the computer system which I think requires an ability to “see the matrix”. Like most people striving for a career in Internal medicine he wasn’t without his quirks. I always enjoy traits about people that at first are annoying and then once the ridiculousness of it is fully appreciated they become amusing. This guy loved the word “player”, not in the pimps and hoes, don’t hate the game kind of sense, but in the “this patient is an ICU player”, or “that doctor over there used to be an army player”, or “the sodium is the main player, and that lab will be an important player”. The only play I played in the game most of the night was my ability to take histories and physicals and scribe them in the time tests biblical format known as the H&P.

For the first 8 hours we got slammed. The patients were typical, Grandmas with chronic obstructive pulmonary disease, alcoholics with liver failure. But they might as well have been snarling hell hounds because when I cut the head off one by admitting them they would somehow grow back in three and the night never died. It would also be an understatement to say that being called doctor was foreign. You see med school is pretend school. You wouldn’t take a 2nd grader that had just finished safety town in the school parking lot and put him on the autobahn with a Ferrari would you? So why is it at night that a bunch of pretend doctors are somehow running a hospital, all the while snickering in the back of their heads thinking “I can’t believe they actually think I’m a doctor. What a bunch of idiots”. At about 3am I said to my resident the player, “I’m thirsty” realizing that we hadn’t stopped for water or pee all night. He apologized admitting that sometimes he ignores his basic bodily functions and keeps pressing. Yes, the things some of us do in the name of self destruction. We took a minor detour between bouncing from one bed to the next in order to get me a 2 ounce cup of water. Around 5am the night started to retreat its fiery red eyes back into it’s cave and the opportunity for food presented which I gladly took.

The last trial of the night was passing these patients off to the team at 7am. I was going to stick around for most of it, but the player told me to duck out early and get my computer access fixed. For each patient that was presented copies of my H&P were passed around the room. This was unexpected, but I should have expected it. See as a med student your H&P is usually ignored, stuffed into the back of the chart to never be seen from again. I wrote 8 H&Ps that night, bear in mind I have not written one in over six months either. As the player presented the first patient I could hardly take watching everyone’s eyes scanning over my notes crippled by spelling, and grammatical errors that a 3rd grader would find hilarious. You see mom and dad, even though I’m a doctor repeating 3rd grade did not help at all! Before my eyes the white coats in the room became darker until they resembled the robes of judges. Pencils became gavels that slammed down and barked out “Idiot”! I quietly slipped out of the room. I found out the next day that the attending physician was “less than impressed with the H&Ps”. Well at least I’m not getting a grade, what are they gonna fire me?

I never planned to devote to much time in Malaysia, but then again I never really plan. Lodged between Southern Thailand and Indonesia Malaysia is a country of contrast. Kuala Lumpur the countries ultra modern capital is worlds apart from the primitive rainforest in the middle of the country that is one of the oldest and best preserved in the world.

My introduction to mainland southeast Asia was through Kuala Lumpur. The most visited attraction in the city is the sky piercing Petronas Towers, that at one time were the tallest buildings in the world. Flanking the Petronas towers is the KL tower. I think the only real point of the KL tower is to ride to the top and look at the Petronas tower. The only thing really memorable about the KL tower was the absurd tourist attractions they had. At the ground level there was a “winter wonderland park”. A 200 meter strip full of the cheekiest Christmas decorations lit up to their full brilliance. It may have been the most random thing I saw on the entire trip. There was also a zoo that even included the rare and exotic raccoon of North America. They were confused when I asked if I could shoot it.

In KL they had some of the largest malls in the world. They actually have specialty malls. For example there is an IT mall I went to that was about 4 stories tall. Each floor sold some different piece of electronics. One floor was the cell phone floor, while another may have been the computer floor, or cameras. The flagship mall was a giant six story mall filled with every store you could imagine. I learned a small lesson in the starbucks of this mall that would be repeated throughout the trip. I ordered a simple coffee and just wanted room for milk. There was of course no creamer by the sugar, when I asked if there was milk they gave me a large cup full of steamed milk for my coffee. The point was that although this mall was probably more modern then any mall at home and they were desperately trying to be western, they were still slightly missing the mark. I would run into this scenario a few more time over the next few months of big businesses trying to impose western standards, but being slightly off in the delivery.

In contrast to the Seattle standard for coffee one morning I walked down a side street filled with street food vendors. There was a larger one on the corner with open vats of different meats and vegetables that I didn’t understand. People would point at things and the guy would wrap the ordered concoction in a banana leaf followed by newspaper to make it portable. I followed and told the guy to surprise me. I didn’t quite understand what I was eating, but was pretty sure that if I deserve to get sick from something it was this, it was actually pretty good. The meat of course could have been anything. In the end I stayed healthy. (medical side bar- In all my travels including the entirety of this trip I’ve never had travelers diarrhea. I am not careful, I eat anything, and hardly ever use hand sanitizer. When I travel I take lactobacillus religiously, other known as probiotics. It has been proven that it helps to regulate motility, but I have another theory that it helps to protect and possibly coat your GI tract so that an invasion from nasty bacteria is more difficult. Or I might just have a stomach of steele, but I doubt it.)

Kuala Lumpur was overplayed in my mind in about a day and it was time to move on. Before closing this chapter on KL it is worth mentioning that my white coat met its fate there. Before I left I Palau I shipped a box home full of all my clinic clothes, medical supplies, etc. The one thing that I dragged with me was my white coat. My only intention of dragging it with me through Asia was to destroy it. The fascination I had was to toss it in a volcano in Bali and get a brilliant video of it burning in liquid magma, unfortunately there wasn’t an active volcano that I could get close enough to. The other option was to take pictures of a variety of prostitutes posing with it and putting them together in a nice montage. This however was shot down once it occurred to me that I would have to lug around an STD infested coat around in my bag. The option I went with was more benign. One of the most popular hostels in KL and all of Malaysia is called the Red Palm. They have a cork board in the lobby full of pictures and things people have left. So I cut off the patch and tacked it up on the cork board, the lady in charge liked it and said she would leave it up.

The rainforest in Malaysia was tempting, there was a variety or 2-5 day treks offered for reasonable prices. However I ultimately decided that I didn’t want to get trapped in Malaysia for too long. At the time this was a reasonable decision, looking back on it I should have done it because it was probably one of the best treks in all SE Asia, but this was impossible to know at the time, well maybe if I had planned ahead in more detail, but…umm… screw that. Instead it was decided to go to and island called Penang and the old colonial town of Georgetown. The bus up the coast of Malaysia was pretty amazing, one of the nicest I’ve ever been on, and unfortunately will be on. The scenery was a mix of steaming rainforests, construction, and rice patties. I didn’t have anywhere to stay in Georgetown on arrival as I usually do not. I think over the course of two months I only made about 3 or 4 reservations. In case your curious this is how it works when on a fairly populated backpacking circuit like SE Asia. The bus dropped me off at the central bus station, I had no idea where I was. I got in a cab and said take me to the guesthouse area. Cab drops me off. I take a rock and throw it in any direction and start asking about rooms and prices, within a few minutes it works itself out and I find a place full of like minded backpackers. The next step is to hang out in the lobby, have a beer, use the internet whatever. The point is to find a hot backpacking spot and start talking to people about their travels and what they have done in town. Within an hour or so its really easy to develop an itinerary for the next few days based on other travelers opinions. With that mentality I met some British girls that I went out to eat with at this bizarre food court/live music area. It was basically a big pavilion filled with tables, in the middle there was a band playing music with some people dancing. All around the periphery there was a wide variety of food stalls. Basically you just order from any stall they bring it to your table and you pay when they bring it. Multiply this by 5 or 6 different stalls and some beers and it’s a pretty good time with some amazing food.

The one full day spent in Georgetown was full of wandering around taking pictures, basically exhausting myself in the heat. The island has a pretty interesting history as I learned from the museum, the only reason I went to the museum in the first place was to get some AC and get out of the heat for a bit. But, this island has been in the middle of a couple different trade routes over the years and has been colonized by a mix of people. As a result the architecture resembles a unique blend of Chinese, British, and Euro-Russian influence. The best example I saw of this was this old German restaurant with Chinese writing everywhere. While I was eating there was a guy taking pictures of everything, which could only mean one of two things. He was either Japanese, which he wasn’t, or he was working. After talking to him the latter was correct. He was a Dutch freelance photojournalist. I talked to him for a while about how his job works. It was pretty fascinating, he basically travels and takes pictures. Sometimes he is given an assignment before he leaves, and sometimes he tries to put something together and sell it with out having any contract upfront. My backup career was established.

Before leaving Penang and flying to Phuket in Thailand I took a tram up a big hill called Penang hill that is known for the view. The top was pretty uneventful except for this one restaurant that was hidden underneath a canopy of vines with signs that said “please watch out of the pit vipers overhead”. So as you ate you just had to keep aware that a poisonous might drop down on you. As I was leaving Malaysia there was a coffee bean in the airport, I decided to give this another try and ordered a coffee with room for milk.. I got a latte.. (sigh)

So keeping a travel journal is hard enough, updating a blog without having a laptop while on the road is another story. Sorry to anyone keeping tabs that I haven’t posted in a while. The time that it takes me to write doesn’t fit too well with the cost of Internet cafes, and always being on the move, but not to worry I have been keeping a pretty solid written journal that I will slowly transcribe onto here when I get home. I wanted to give a quick update and just list bullet points about where I’ve been, more of an appetizer for future posts.

 

From Bali I went to Malaysia which was pretty boring so I skipped on over to Southern Thailand and did the beach/party/rock climbing/island hopping scene for about a week and a half. Went to Bangkok for a bit then went to Chaing Mai in Northern Thailand. Stayed in Chaing Mai for two weeks, rented a motorcycle and toured northern Thailand for four days, say a nauseating amount of waterfalls and temples. Stayed in Chaing Mai for the Thai new years called Songkran which was the biggest craziest party I’ve ever been to, blows Mardi Gras out of the water.

 

From Thailand I took a slow wooden boat down the Mekong river in Laos for two days to get to a place called Laung Phrabang, did the whole temple sightseeing thing there for a few days before doing what everyone comes to Laos to do which is to go tubing in  . Basically a bunch of drunk tourists on this river with about 6 bars spread over a short distance, filled with rope swings, trapezes, and lots of injuries.

 

After Laos I went to Siem Reap in Cambodia to see the temples of Angkor Wat for 5 days, think Tomb Raider and Indiana Jones. Then I went to Phnom Penh to basically learn about the terror that riddled Cambodia in the late 70s. Although they still have a healthy stock pile of munitions laying around and if you really wanted to you can shoot bazookas at cows. Some nice night life there as well.

 

For the last leg of the trip im staying in a beach town in southern Cambodia called Shainoukville and just chilling for a few days before heading back to the not so Big Easy.