Phnom Penh Journal, Vol. 3- No. 2---At Brown Coffee

The first day at Sihanouk Hospital we began rounds as usual around 9:45.  The goal was to start at 9:00, but times are not rigidly adhered to here and a combination of the residents finishing their morning examinations of the patients and the time Kruy Lim needs to deal with her overnight email and ER patients and whatever personnel issues are looming determines when we actually begin. 

Rounds start at Bed 1 and finish at Bed 14; no bed is visited out of order, except Bed 2, which geographically is next to beds 11 and 12.  I write Bed rather than bed because patients are not identified by their names, but by their bed numbers.  This is useful to the visiting teacher because it is very unlikely we would either be able to pronounce the patients’ names so that a Cambodian nurse or doctor would understand us, or that we would be able to discern among names that are sometimes nearly identical. 

When we stop by the ward from time to time during the day, the residents give us a quick update—Bed 4’s repeat sodium this morning (96 yesterday) is now 120 . . . the abdominal ultrasound on Bed 2 showed a small splenic abscess.  

It is always a bit of a shock to begin teaching at Sihanouk Hospital because of the complexity and severity of illness of many of their patients.   Often their problems are unfamiliar to an Oregon physician.  Each year we have cared for two or three patients with Burkholderia (melioidosis), an infectious disease that I only barely recognized from my medical school tropical medicine course and had never diagnosed or cared for.  We have already had three patients admitted with miliary (widely dispersed) tuberculosis.  On day 1 we met two young women with severe advanced lupus—a disease in which the body develops antibodies against its own cells with resulting deterioration in virtually every organ.  Left undiagnosed or untreated lupus can lead to early and rapid death. 

The patient in bed 6 was a thin young woman severely short of breath, breathing at a rate of 40-48 times a minute, a look of desperation in her eyes, constantly moving as she tried to find a position in which she would suffocate less.  The large group of us rounding was tightly gathered at the end and side of her bed, listening to the details of her admission and diagnosis a few days earlier and her lack of progress.  She had not been previously diagnosed or received treatment for a combination of organ failures including carditis (inflammation of the blood vessels of her heart) leading to heart failure and fibrosis and inflammation of her lungs.  She had been started on drugs to treat each of her problems but seemed to be getting worse.  Kruy and her residents see many similar patients and among the visiting teachers there were more questions than suggestions of additional or different treatment that had not already been considered. 

At her bedside day and night was her single family member, a daughter of 13 who attended to her constantly—helping her squat beside her bed if she was too exhausted and short of breath to walk the 100 feet to the toilets, bringing her the little bits of food she would eat from the carts on the street outside the hospital, massaging her back and arms, cleaning her, trying to help her find a comfortable position (there were none).  We would often find her sleeping beside her mother, leaning forward to share her mother’s pillow.  She was with her night and day for two weeks.  

Over the first two days Bed 6 repeatedly appeared close to dying —frantically struggling to breathe, terror in her eyes, haunting us with our inability to do anything more.  We gave her small amounts of morphine and she would sleep for an hour or two, and then again her breathing would accelerate to unsustainable levels.  The work of breathing ate away her main source of calories, her muscles and whatever fat she had left. 

And then, after two days, treatment of her lupus with prednisone and drugs for her heart failure began to take hold.  She began to have periods when she was calm and breathing perhaps at 30, able to sleep for short periods without morphine.    Although a few hours later she would be again struggling to breathe, these spells became fewer and shorter.  At the end of five days other problems began to emerge—bleeding from her bladder; inability to urinate, making the use of diuretics (drugs to move fluid out of her lungs) hard, since if we were to use them she had to be able to pass urine.  Use of a catheter was painful to her and we repeatedly failed to insert even a small one used in children.  A surgeon hovered as we considered putting a catheter through her abdominal wall directly into her bladder to bypass her obstructed urethra.

And then even that problem resolved.  We saw her every few hours through those days and gradually she would smile, press her hands together to welcome and thank us at each visit.  As we were able to think about her leaving the hospital the stark details of her life emerged.  She had two children, one too young to be at the hospital, now in the care of someone in her village.  She and her husband had been farmers, growing a little rice.  He had disappeared and his parents were dead.  Her own father lived far away and was demented, and her mother was dead.  She had no cousins or aunts, no brothers or sisters.  She was utterly alone to feed and clothe and shelter her daughters.  Beyond her small crop of rice, her only income was pushing a cart around her village to gather cans and bottles—a chore hard to imagine her resuming.  

Through our resident Kosal I asked if she had money.  She has none.  Do you have money to buy your food here at the hospital?  She had a little left from what she brought, about 10,000 real or two and a half US dollars.  I asked if she would allow me to give her money—about ten dollars—so that her daughter would have enough to buy food for them for the rest of her stay.  She squeezed her eyes shut, bowing her head, raising her hands again to express gratitide.   She says now we can have more food.  An hour later her daughter appeared with several plastic bags of food and two iced drinks!  They had been eating rice gruel. 

A few days later she was ready to go home.   I asked Kruy if it would be possible to visit her in her village.   The patient said the tuk tuk could only go part way to her village, and then the road was blocked.  Someone would have to take her on a motor bike the rest of the way.  Kruy said you cannot go, it is not safe.

Every year at least one patient breaks my heart.  Bed 6 broke many of our hearts.   A neurology resident visiting from the Mayo Clinic was worried about what would happen to her daughters if she died—they would be orphans and the plight of orphans in Cambodia is sometimes unspeakable.  He said he would like to find a way to pay for the daughters to go to a residential private school if she could not care for them or died. 

She would need follow-up care soon after discharge.  The trip would cost her $10 each way and without the clinic’s help she could not afford her medications. An arrangement was made to pay for her clinic care in a week.  I gave her money for the trip and for a month of food.  More money accumulated from others—I don’t know exactly who gave what or when it will run out.  Life is often measured in dollars at Sihanouk Hospital.

A few days ago, while seeing another patient on rounds I noticed that bed 6 had become empty, stripped of its sheets.  Bed 6 had walked out of the hospital with her daughter.  Had she not been admitted two weeks before, had there been no available bed, she would have died. 

The Patient in Bed 6 and her Daughter

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I arrived from Chiangmai through Bangkok on a Friday afternoon.  The flight to Bangkok at 10 AM took 75 minutes; flying at 1:00 to Phnom Penh took 90 minutes.  On each flight an entire meal was served, a cold breakfast on the first, a hot lunch on the second.  The meals and drinks are served efficiently and quickly, in full planes.  I would not fly to Phnom Penh just for the lunch, but it is phenomenal how Asian airlines have preserved a level of gracious service and decent meals for economy passengers, on flights barely long enough to warrant water and juice service in the US. 

In Phnom Penh the road traffic and dust are intense, but the people are soft and welcoming.  A taxi from my guest house met me.  At le Safran, where I stayed last year, I felt like a friend arriving for a visit and not a customer.  Thira, the young woman who lugged my suitcase up the stairs (I swear, she insisted) would have fit inside and weighed at most 40 lbs more than it did.   

When I walk by the reception desk, the several staff members stand up and pay full attention to anyone, guest or visitor.  I am so unused to this kind of service that on the first day I almost  saluted and barked “at ease”  (I did this exactly once in my military career, to astounding effect, but I am saving that for another journal, A Montana Naïf in a Major’s Uniform).  

The rooms at le Safran are beautifully spare, decorated with modern paintings and interesting lighting and simple furniture—just enough shelves and hanging space, immaculately clean, always fully made up within minutes of my leaving.   Last year I rattled around in a huge “deluxe” room with a long balcony overlooking the pool and enough space to play badminton.  At $55 that seemed unnecessary and my $38 room this year seems like a bargain given the breakfast, comprehensive service, furnishings, and warmth of the staff.  About half the guests are French, the rest a mixture of visitors from the English-speaking diaspora. 

I am up before dawn here as at home.  Walking outside at 4 AM, the streets and guest house are quiet except for bird songs, the small grounds smelling of the trees in flower.   The tuk tuk and moto drivers and some of the staff sleep on the cushioned benches around the terrace and outside dining room because their homes are too far away.  

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I timed my arrival to be able to go to Kruy’s father’s 87^th birthday party. Claire Zeigler, a chief resident at OHSU who also has come to teach at Sihanouk Hospital, joined me at the party, although she had just arrived after a very long and mostly sleepless flight a few hours before.  Our tuk tuk trip to Kruy’s house was serpentine—beyond the Russian market the houses and streets are more heavily residential, with less of the office building construction happening in many other sectors.  Our path was broken several times by construction that closed streets, and by weddings in tents set up in the middle of the street.  Once on the right street, we had trouble spotting the house:  the numbering of houses is quixotic, perhaps reflecting the order in which houses were built rather than progressive from one end of the street to the other.  We finally spotted the lush gardens overflowing the terraces of the upper house and an aunt or two waiting for us.  Immediately we were awash in introductions and hugs.  I believe some of the people who hugged Claire and me had no idea who we were but recognized that there was a fuss going on:  there just aren’t that many tall blonde young women accompanied by diminutive antique professors in that part of Phnom Penh. 

Inside the main floor--already full of furniture and many years’ accumulation of the apparatus and keepsakes of long lives—was crowded with 160 people, at least half of them children.  We were introduced as we made our way under Kruy’s guidance, to a round table thoughtfully filled with English speaking cousins and nephews and nieces.  Kruy and her sisters had been cooking for several day; all the Chinese dishes for eleven of the twelve courses had been prepared by them and arrived one by one at our and the dozen other tables in bowls from which portions were ladled into our smaller bowls by neighborhood girls brought in to serve and clean up.  Each dish had a name that wished a long and happy life.  Probably the shark fin soup had been prepared from real sharks, but fortunately the dish named Dolphin was topped with pickles shaped like dolphins and no real dolphin had been invited to participate. 

There were dozens of children sitting at and passing by our table; almost all, if not too shy, spoke perfect English inflected with Americanisms that were startling coming out of small Khmer mouths.  Many seemed to be attending the International School, taught half in English and half in Khmer, with a curriculum comparable to western schools.  I got started in a back and forth teasing conversation with the most outspoken of the children, a seventh grader.   She was scolded by her aunt and told bluntly to be more respectful.  I confessed that it was all my fault but the aunt was unrelenting—there could be no excuse for disrespect of an elder.

I had thought this was a special birthday party.  Kruy said they started the birthday party many, many years ago to bring the family and all of their friends and her father’s business associates and their families together.  The menu was exactly the same every year.  Those attending asked that everything be kept the same.  Kruy and her sisters knew everyone in the room and every child by name and history, and they all knew each other. 

Several hours into the party there were three pink birthday cakes flashing light sticks.  To keep the children interested, there was a lottery.  Every guest got a number and a gift:  Claire got a helicopter (not real) and a dress for a one-year-old girl.  I got a pot to heat a lunch dish.  

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My friend Daroth has given up her tumultuous and stressful job managing a Pakistani restaurant.  After a year of trying to quit and then being talked into coming back, she finally succeeded in walking away.  Daroth has a large family for whom, as the oldest child, she is responsible.  Her sister Srey Pich has ended an unsuccessful marriage to a Korean who came to Cambodia to find a bride.   Now with her mother she has a shop in a small market on the fringe of Phnom Penh doing hair and make up.  Daroth has joined them.  She now earns a fraction of her manager’s salary; at the restaurant she also got her meals and slept upstairs with two country girls who worked for her.  Now she commutes to and from home on rough roads to her house far beyond Phnom Penh with her mother and Srey Pich, squeezed together on a small and deteriorating  motor bike.  From home to the market is an hour; to central Phnom Penh, two hours.  There have been many crashes over the years.

I have written about Daroth and her family in the earlier Journals.  There has never been enough money.  Daroth has loans to pay for the completion of her house for which the monthly payments leave very little from their three salaries and what her father sends home.  Her computer has now-outdated software and has become extinct; she has no internet. 

Daroth’s sister Dany has attended a Catholic boarding school for girls; boys come for classes but do not live there.  Daroth told me that the school charges her $18 a month for board, room, and schooling.  When I first saw Daroth she said she had not been able to pay in December or January.  I gave her enough to bring her up to date.  Her mother drove two hours to pay the bill the next day.

Last weekend her friend Vannak, a tuk tuk driver who stationed himself outside of Daroth’s restaurant for years, drove us to Dany’s school, where I talked to one of the senior nuns, Sister Ched.  I was impressed with the care the school takes for each of its students, the comprehensive curriculum, and the number of students who, like Dany, have no money.  Dany is a very good student and happy at the school. 

 Dany, Sister Ched, and Daroth

The Seventh Grade

Don Bosco School

I asked if I could pay for Dany’s school for a year; Sister Ched wrote out what it would cost.  I was doubly shocked to see that the full cost of schooling was $35 a month, and room and board another $35.  Shocked because $70 a month was so much higher than the $18 I had been planning, and shocked because in reality $70 a month is just a tiny percent of the charges for a boarding school in the United States.  I asked Sister Ched--if I send you what Daroth’s family is paying will they have no further obligation?  She said the family would have no charge; the nuns would try to find another sponsor for Dany to pay the rest.  Many other girls have sponsors and they are always grateful when a new one appears.

Coming from a poor family, Dany’s hope for the future depends on education.  Even English-speaking young women who graduate with a bachelor’s degree in business earn only a few hundred dollars a month as secretaries or accountants.  For the next year I will pay beyond what Daroth’s family have been paying; if she continues to get good grades I will continue for a while, but the stretch through high school and college will require others to invest in her as well. 

Neither Daroth nor Srey Pich finished college—they began work at 20  to support their family.  Daroth was lucky to have a benevolent friend hire her at a good wage with food and a room for seven years.  Now she cannot find a similar job.  To work or study in Phnom Penh she would need her own motor bike (she could not afford a room in the city).  To improve her ability to care for herself and her family, she needs to study more English, become facile with the use of the internet (surprisingly few are), and then learn skills that thousands of others do not have. 

Her dream is to go the United States.  Neither her experience nor skill ratings as a restaurant manager or hair stylist qualify her to enter the green card lottery.

Daroth often asks me if I can find her a husband, a good man with a good heart, not a Cambodian man, but an English or Australian or New Zealand or Canadian, or US man.  I laugh and tell her I am not in that business.  “No problem,” she says.    I have no idea what that means. 

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A few days ago I was able to change my flight back to the US at the end of this week.  My original booking required that I go back to Bangkok to catch a United Airlines flight to Portland, with a two day layover in Bangkok to be a tourist.  Since leaving Chiangmai two weeks ago the conflict between those protesting and those supporting the government has spiraled into bombings and shooting.  The protestors blocked early voting last week and one was killed.  Yesterday an open running gunfight broke out in the airport’s district between the two factions.  Voting is today, but there have already been massive blockades of polling places all over the country, especially in the south, which heavily supports the protestors. 

From the New York Times Today

The protestors hope that with many districts not able to vote, the Election Commission will declare the election null.  They hope that the caretaker government of Yingluck Shinawatra will then be unseated by a military coup.  Civil war seems possible if not inevitable.

Thailand goes through political upheaval and coups every few years, and always it recovers quickly.  But many think the differences are now so vast that public institutions such as respect for the royal family and courts are crumbling.  The vast royal family itself is torn into factions before and against Yingluck and her party.  There is now talk of two Thailands, Bangkok and the south permanently separated from the north, as it was in the 1800’s and for centuries before that. 

We are in the middle of the Lunar New Year.  Every year tens of thousands of Chinese come to Thailand for the five-day holiday.  Travel agents in Hong Kong and Shanghai and Beijing have reported that this year there were no bookings at all.  Flights into Bangkok are half empty when usually they are full.

My friend Tom Cooney helped me master changing flights among the various Asian airlines affiliated with United.  I am bringing back bottles of Angkor Beer to thank him.  I was going to add a small packet of deep fried tarantulas to eat with the beer and then remembered that he is now a vegan and so doesn’t eat arachnids.  What a shame. 

Bathrooms in good restaurants and hotels in Phnom Penh have spray hoses next to the toilet.  The person ahead of me in Brown Coffee’s men's room  appears to have taken a shower with the spray:  the floor was pooled with water, the toilet paper sodden.  A small fish flopped out the door as I entered. 

Now I am prepared for anything.  

Brown Coffee

Phnom Penh Journal 2014--From Chiangmai

Two days ago I left Portland to spend a month in Phnom Penh teaching at Sihanouk Hospital.  When I travel this far away from the Pacific Time Zone I have many days of jet lag, about a day for every hour of time difference.  Trying to care for patients and teach when I am jet lagged is hard; when I go to Japan and Cambodia I spend a few days as a tourist, with no fixed timetables or lists or responsibilities.

Now I am in Chiang Mai; I have been awake since 4:30 am.

Chiang Mai downtown near the old city is deserted at this hour, except for a rat or two policing the gutters.  The cats and dogs that wander everywhere seem to have better things to do than harass an earnest rat—some of them outweigh the skinnier cats.   I went in search of coffee and bought the first- ever anything from a Burger King, open 24 hours a day—the staff in Burger King seemed as startled to see me as I was to see them.  Their cappuccino wasn’t bad, but at this hour my standards may have slipped.  45 baht, about $1.50. .  I passed on the croissant with cheese, bacon, and ham (about $3.00).  There was one other customer there, a student who seemed to be spending the night studying. 

My trip went smoothly in spite of the enormous demonstrations now occurring in Bangkok.  A substantial portion of the Thai population wants to unseat the long-standing ruling Pheu Thai party that has been in power for about 30 years in spite of repeatedly being found in the courts to have been corrupt.  The Pheu Thai have controlled Thailand in spite of numerous coups that threw party leaders out.  The demonstrations in 2008 shut down the Bangkok International Airport for 8 days, with a devastating impact on tourism that echoed for several years.  The overturned prime minister, Thaksin Shinawatra, fled, but he has continued to rule through his sister, Yingluck Shinawatra, also a member

of the parliament, in a caretaker government.   

Yingluck tried to pass a blanket amnesty that would have allowed her brother and many others to return to Thailand, throwing out the court cases against them.   This led the main opposition parties to resign en masse from parliament.   With supporters pouring in from the south, mass demonstrations have shut down major streets and business and government areas.  Yingluck  called elections for 2 February to refill the empty seats, but the opposition knows it will lose because a majority of the voters are northern rice farmers and others who benefit from the policies of the Shinawatra government. 

The standoff has being going on for more than a month.   In the most recent demonstrations there have been killings of some protesters and government supporters, and bombs thrown into crowds with injuries to dozens.

I had been concerned that the protests might again shut down the international airport and abort my trip.   In central Bangkok there were substantial delays for people going to and from downtown hotels or their homes to the airport, but the blockades were mostly in the busiest business streets and mass transit exchanges.  The government persuaded the demonstrators to let those taxis licensed only to operate at the airport to pass—but the US and British government are advising that tourists and business people arriving and leaving the airport allow four hours for the trip.

To avoid the protests and possible violence I decided to spend a few days in Chiangmai rather than Bangkok.  On arrival at the Bangkok airport on Monday I stayed at the hotel at the airport--checked in at midnight and left the following morning at 8 AM for the 5 minute shuttle ride.  There were huge crowds in the airport:  I could see no apparent effect on air travel for people going to other parts of Asia, to the beach destinations in the south of Thailand, or north to Chiang Mai.  

Once in Chiangmai I spent Tuesday afternoon walking around the Old City near my hotel.  The only evidence of the protests in Chiangmai was a small noisy demonstration outside the Tha Phae Gate when I came back from the Ping River after dinner.  Two bored men were parked in a truck in front of a Starbucks, smoking, while a recording announced the “Red Shirts’” support for the government and civil war to death if there is an attempt to overthrow it. 

Two days later the Red Shirts’ leader in Chiangmai was shot but not killed. 

Chiangmai is not so much nestled  among Thailand’s highest mountains as it is metastasizing aggressively into them.  It was In Chiangmai in 1296 that three kings agreed to stop their fighting and merge their kingdoms into the Lanna kingdom that ecompassed all of northern Thailand.  At that time Bangkok controlled the lands to the south, from which they gradually pushed out the Burmese, but Bangkok had no influence in the north.  The northern hills were the home of many tribes and cultures, now substantially mingled; the pre-tourist economy was largely rice, trees (teak especially), fruits, and fiber.  Like much of SE Asia, in the rural areas people could forage subsistence from what grew naturally around them or could be easily cultivated. 

Now the Old City area of Chiangmai is heavily focused on tourism, mostly tourism outside of the city on the mountains and rivers.  The Old City is a square 3 km on a side, richly dusted with Buddhist temples, guest houses, and businesses.  In three days I walked through about half the streets and my incomplete survey tallied:

182 shops devoted to bus and tuk tuk and truck transport to tourist sites (elephants, washing elephants, riding on working elephants, looking at monkeys, rafting rivers with rapids, cruising rivers in long-tail boats, bungee jumping, zip lines zipping, treks in the woods of 1, 2, 3, 4, 5 days, visiting hill tribes and farms and orchards.  These shops were also renting taxis to visit surrounding small towns, arranging flights to the beaches to the south, selling helicopter flights, and arranging authentic home visits to authentic homes where you could talk with, eat with, and sleep with authentic Thai people, with the fulltime assistance of an interpreter. 

Over 400 shops for Thai, oil, body, foot, head, and spine massage (Thai massage about $3 for an hour). 

Nails and make and hair—111.

Small shops selling local dishes, mostly along the streets, or open but under cover—over 200. 

Restaurants with names and cuisine and posted menus accessible to the farang—about 150. 

Coffee shops, also about 150, and they mostly sell food as well.

Temples with historic relics or important roles in northern Thai history—32.

Temples with Monk Chat—1.  “Talk to a monk and ask about the meaning of life; what it feels like to be a monk; why you chose to become a monk; monk daily life; why monks’ robes are saffron”.    

67 shops for repairing bikes, motor bikes, cars, machines of all kinds, and selling gas.

Supermarkets—zero

Large street markets selling fruit, vegetables, meat, fish, cooking equipment—14. 

Convenience stores—2

Pharmacies—over 40

Burger King—1. 

Shops selling clothes, cloth wares, shoes, watches, suitcases, back packs, fabrics—too numerous to count. 

There is nothing “fixed up” about the Old City.  It is just that, an old city—the buildings and streets are old, there are few expansive houses, and only the corporate restaurants have gloss and shine.  The sidewalks, where they exist, are filled with everything that will not fit on the street. 

People are friendly and talkative.  The vast majority seem to work and live there.  About 2-3 % of the western farangs appear to be expats, their skin brown as roasted coffee beans, their dress and hair indifferent, and they make their rounds speaking fluent Thai (or at least they are quickly understood). 

My hotel is in the Old City.  Three quarters of the other guests are Asian, and most of the Caucasian’s are northern Europeans.  Although nearly every tourist speaks at least some English, I heard far more Danish and German and Norwegian and Swedish than Australian or British or American English.  Spanish and French were uncommon. 

There were lots of backpackers, mostly moving through the streets in twos and threes, large pack behind, small pack in front, hair sometimes so profuse that it covered the top of their packs, on their feet everything from hiking boots to flipflops. 

Chiangmai food is amazing.  The common dishes, sold in the simplest restaurants, are best.  No meal cost be more than 6 or 7 dollars with a beer.  As in many places, the more upscale restaurants with a view and comfortable seats had mediocre food.  I ate four meals a day. 

 Pork boiling in a market

Dinner 15 January Lert Ra, grilled tillapia with steamed rice and green papaya salad. The experts pick the tilapia clean except for the bones   

Breakfast on 16 January, khao ski with a chicken drumstick.  Wonderful.  50 baht, about $1.50

Lunch 16 January, Cooking Love, green papaya salad

And wide northern Thai noodles with fried rice and chicken, cashews and vegetables 190baht with mango lassi, about $5.50

Dinner 16 January, again Cooking Love, vegetable spring rolls

 

with a main course of shrimp and vegetables, with a Leo beer, 290 baht about $9

Chiangmai served its purpose.  My jetlag peaked and began to ebb, I had the luxury of two afternoon naps (my last nap was in 1946 and then only under protest and I am pretty sure I faked it so that my grandmother would leave me alone:  she believed in lots of sleep, a daily bowel movement, and clean fingernails and she regularly checked on all three). 

The time was too short to arrange a day away in the mountains.  Having already seen two people’s lifetime quota of temples, if I go again I will focus on trekking.  With trekking you don’t have to keep taking your shoes off and putting them on and worrying about where your toes are pointing.

I skipped “Monk Chat.”   The one on duty was asleep and I hesitated to wake him.  I don’t often pass on opportunities to learn the meaning of life, and I am curious.  It may have been my last chance. 

Now I am off to Phnom Penh. 

Woods Bay Journal End of Summer, 2013

Woods Bay Journal

Draft 9-2-13

The first story, in which I tell about becoming left-handed

The summer is nothing like what I had been planning for.  I had been planning to hike the Norwegian Fiords in September, and to work in Haiti for a week in October at a medical clinic staffed by Oregon physicians.  Before those trips I had expected to put in a vegetable garden here in Woods Bay on the shore of Flathead Lake, thin my grandfather’s ancient apple trees from a high three-legged ladder, try again to outsmart cutthroat trout in the North Fork and the bigger Mackinaw trout in the lake, build a shed of storm-delivered dock planks to store wood and garden pots, take a shovel to burgeoning weeds that in Montana grow to the size of small trees in just a few months.  And I was going to spend cool mornings working on a memoir started in Tokyo but put aside for eleven years because I allowed the dense schedules of medical school work to eat up all but a few hours a week.

None of those summer projects happened.

In May, in a one-in-a-million accident while navigating Argo the Dog around a monumental pile of dog poop, I tore up an already messy right shoulder. Two of the four muscles that make up the rotator cuff had torn away from the humerus and had retracted 4 cm.  I could not elevate my arm more than a few inches.  Toward the end of June I submitted to arthroscopic rotator cuff surgery and eight weeks of an immobilized right arm.  There was really no choice:  physical therapy alone would not have given me a functional arm.

The surgeon warned me

This surgery is enormously life disrupting.  For two months you will be in a sling and cannot use your right arm, so that the mending tendon will not tear off the bone.  You can dangle the arm three times a day.  You’ll have to get along with just a left arm.  And for some reason this particular shoulder surgery is inhumanly painful

Most of my memories of the early weeks with my right arm in a sling are blurry or simply missing—I spent long days and longer nights trying to reduce pain (oxycodone and a “GameReady” icing machine), trying to find a comfortable position (there were none), and trying to maintain a little dignity in spite of the fact that I couldn’t fasten my own pants or button a shirt.

For a person whose only left hand skill is to pass something to the right hand, to say that the surgery is “enormously life disrupting” is enormously understated.   I had never learned to do much with my left hand—just those things that either required two hands, or that were too awkward to do right handed—certain under-cabinet supine plumbing repairs, for example, or holding a nail or board steady, or propping my waltz partner’s right arm at a graceful angle. 

Looking at my first attempt at a grocery list, Margaret broke out laughing.  “This is illegible.  A caveman with a rock could do better.” 

Although my left fingers can do half the job of touch typing at 70 words a minute, that is of little use if the right hand is in no position to participate.

Chopsticks?  My first (and only) attempt to use chopsticks left-handed resulted in one flying over to the table next to me, the other to shoot to the ceiling.  The waitress was astonished and then disappeared to the place where waitresses go to laugh or scream. I think I saw tears running down her face.  Did you know that in some Japanese restaurants you are practically ushered out the door if you ask for a fork??

Showering, shaving, using dental floss—the simplest, most humble everyday tasks that I thought I could do blindfolded with one arm pinned behind my back I found I could not do if the pinned arm was the right arm—even without a blindfold.

Since I couldn’t garden, couldn’t build things, couldn’t fish, couldn’t drive, the computer and email should have been my salvation—but with one finger I type 7 words a minute.  Badly.

A friend suggested dictating—who knew that if I upgraded Lion to Mountain Lion I would have dictation on my iMac?  How cool that a student pointed out that I could dictate on my iPhone.  This was clearly going to be my solution to responding to twenty-five or fifty emails a day. 

Voice-recognition was a disaster.  I have always believed that most upper-Midwesterners have perfect diction—radio announcer, accentless diction.  After all, Chet Huntley and Tom Brokaw came from this part of the country    But with my clearest, painfully exaggerated enunciation, half the sentences had to be retyped, painfully, one-fingered. Lacking context the dictation genii cannot tell “threw” from “through,” “bread” from “bred,” “Gordon” from “Garden” from “Go Drown.”

Some samples:

About what else are you a total junkie? à About what I’ll see you a total chunky.

The recipient of this said only her mother could get away with calling her “chunky”

Can we Skype tomorrow à Can and scrape marrow

I am NOT sleeping on two piddles

Nor do I also have a hole in Montana

Near Marlborough, NZ, where the great sauvignon blancs  grow à  for the great something old box come from

Both should do you a lot of good à bullshit do you a lot of food.

We live just 4 miles south of Bigfork on woods Bay à we live just for myself before Wednesday (okay, some people might say the dictation program got that one right)

Troubles with names:  Katharine is “Catherine,” Margaret is “Martin,” and Jenny is “Beefalo”. I am now Court, Gorgon, Courtney, and Gardenia.  My orthopedic surgeon, Dr. Gramstad, is Dr. Grandstanding.  My friend Tom has been “Thong” and “Dawn” and “Tedium,” and of course Barbara is “Barbeque” and “Bargain”

And then there was this masterpiece:

Part 1:

You. I am so delighted that your exam was normal

Management of your [disease] make it a little easier this year if the stress level around each examination proceedings, as it often does suck

The unknowns of course our illness, something going on outside medical school, illness, and your menstrual cycles. I wish I had a magic Juan… (Don’t we all wish that we had a Magic Juan?)

Part 2:

My arm duration (situation) sucks

This time the limitations of being without a right arm distill down to being unable to get in the cold Flatlake wise guys please (cold Flathead Lake water when the air temperature is 90 degrees), inability to type with two hands, inability to Drive.  I have a fairly continuous shoulder pain if I try to do any Hedegar (I don't know who Hedegar is, but she sounds enchanting. What I meant was any heavy garden work)

As in most things in life, the real issue is ambiguity. At the end of all this, I won't know whether I will have a functional arm for another month. I leave the slang (sling) at the end of August, and September will tell.  (Yes indeed, there is much less slang around here now!)

We had  good friends who came by on their honeymoon trip.  A lot of fog a lot of food a lot of 105.  (fun, food, wine)

Fondly GOF  (Apparently GOF hangs out with Hedegar)

In the sling/slang

Left handed baking--
cinnamon rolls

The second story, In which I explain why total strangers share intimate information with me

A few months ago one of my medical school friends told me about a patient who hadn’t been friendly with much of anyone until he spotted among the students and residents at his bedside a woman who was about seven months pregnant.  He asked if he could put his hands on her belly, and then he began a chant to bring good luck to the mother and baby.   The student later told me that having her belly touched was not that unusual. 

I asked around among women who had had babies if they also had had their abdomens possessed.   

Did people often ask to touch your baby when you were pregnant?

All the time.  They didn’t always ask.

Friends?

Perfect strangers.  Imperfect strangers.  It is as though I suddenly became public property.  I would see a certain look in their eye and know before they did that they were going to pat or stroke or put their heads on my belly.

Other women have told me the same thing. 

Sometimes women said surprisingly intimate things, I mean things like how I walked or how big I was or how my hormones must be raging.  Even my mother wouldn’t say those things to me. 

Sometimes men were totally inappropriate, like ‘I wish was I was that baby’s father.’

Perhaps this doesn’t mean what I think it does. 

So,  what is it about wearing a black sling with an eight-inch thick abduction pillow strapped to your torso that provokes a constant stream of strangers to stop and tell that part of their life story that includes their rotator cuff surgery, and expect you to listen as though they were delivering a great gift?   If I am any place with more than a few people, I get approached about once every four minutes—brew pubs, the grocery store check out counter, the furnace service guy, every tenth walker on the Swan River Trail, men, women. 

Oh man, that sucks.  I had that a year ago.  (big smile, as in, I am glad it is you and not me)

No matter how painful they have told you it is going to be to start rehab, they are lying.  It will be worse.  Much, much worse . . .

Waiting for a plane flight from Kalispell to Seattle a few weeks ago, a woman about my age looked over at me. 

How long you been in that contraption.  Inhuman, ain’t it?

Umm.  Kind of.

I had it you know.  Went back to work after two weeks.  Living by myself, needed to pay the bills. 

Uh huh (can you tell that I am trying not to encourage this conversation)

Did the rehab like crazy.  Look at me now. 

To illustrate the “look at me” she put her right arm behind her neck and buried her little finger in her left ear canal.  And twirled it 180 degrees

Don’t worry about it.  You’ll be able to do that too

Ok, great, you have restored my hope; putting my finger in my earhole is right at the top of my rehab priorities. 

If I am with Margaret –

What did you do to her that made her do that to you.  (invariably followed by laughter)

At one of the many moments of feeling sorry for myself, I walked into our local microbrewery to get a pint of their fabulous IPA.  An attractive woman of about 40 sitting in a group gave me a really, really warm smile.  I thought, okay, so maybe having an arm in a huge black sling and three weeks of unshaven beard don’t make me look pathetic.  Maybe I look hot.  I smiled back a warm, unshaven square jaw Abercrombie model smile, a really, really, really warm smile.  I was pretty sure that I was radiating  handsomeness.  She pointed at the massive elastic bandage wrapping her upper arm—her dazzling smile had blinded me to the obvious.  We had a nice, ain’t-life-interesting-when-you-have-had-right-shoulder-surgery conversation.  She did not ask for my email address or Facebook name. 

The third story, in which I tell about two magnificent Nordic Goddesses who carried me on their shoulders. 

The Flathead Lake house requires a lot of hard work quickly at the beginning of the garden and orchard season.  In Portland I have a long gentle spring to clear away last-year’s dead foliage, make an early skirmish against the weeds, prune shrubs and trees, and put in annuals where there are still open areas in the perennial beds.  In Montana, most planting cannot be done until after last frost at the end of May.  From that point on work that can be done in two months in Portland had to be done in one month here. 

I came out to Montana by myself in early June, several weeks before surgery, depressed by the prospect of a yard that would be unkept for a whole year, and with no easy solutions—the high school boys and girls I had hired to help me in the last few years were now all moved on to more profitable—and less sweaty—summer jobs.  I wrote to several of them and heard back from Bailey Hughes, just returned from her freshman year at Carroll College in Helena.  She thought that twins she knew might be able to help; one had spent the past few summers helping to care for some large gardens in Bigfork. 

In a quick exchange of emails, Jenna and Jesse said they would come by in a few days, on a Saturday morning.  It was not much above 50 that morning, but in Montana 50 counts as summer and they came in tank tops and shorts and boots and serious-looking gloves.  Both were tall—six feet or more--and slender and muscular. Did I say they were radiant?  And powerful!  Together we managed to weed almost all of the three perennial beds and the rock garden behind the house in four hours.  And then they cleaned out last summer’s 30 X 20 foot vegetable garden, hoed out the weeds, created shallow troughs for seed, and planted corn and beans and peas and tomatoes.

Correction:  it turns out that Jesse, who is not a seasoned gardener, could not distinguish between pea seeds and beans seeds.  She planted six 20 foot rows of beans.  We have had quite a crop and neighbors are beginning to drop their shades and bolt their doors when they see one of us coming with a pillowcase full of green beans. 

For the entire summer, Jenna and Jesse have cared for the yard—and during the long weeks after surgery, they gave me the most beautiful flower gardens and vegetables that, without their help, would have been infested with weeds and dead flower heads.  I often dabbled in light one-handed weeding while they chatted constantly with each other.  They often broke into song (Jenna is close to a professional singer).   One day Jenna cleaned grass and weeds out 70 feet of raspberries in about six hours, a job that would have taken me days and a lot of complaining. 

Each already worked a fulltime job, and the squeezed in the gardening in the evenings between 5:30 and 8:00, or in the early morning.  I doubt that either of them needed the money as their motivation—they simply were responding to someone who needed a hand—literally.

The rock garden after
Jenna and Jesse weeded it

Jenna in the raspberries

Jenna cleaning out the 
vegetable garden

The fourth story, In which I reflect on writing at Woods Bay at the end of summer.

My plan had been to write every day this summer.  In the spring I finally figured out a way to organize a memoir that might be 7% less boring than my first attempts eleven years ago.  I have been thinking about exhuming the memoir since then, but I could not imagine that the stories of my particular life would be of interest to more than 12 people (I counted).  But now I have grandchildren who might enjoy knowing something about their grandfather’s growing up in Montana in the years following the depression and the Second World War.  And I find myself telling stories from different parts of my life often in conversations with students and residents when we are musing about one or another of the timeless problems of becoming a physician or inhabiting a full life.

But the sustained writing I have done in the past has always been when I am alone.  Not alone in a room at a desk, but isolated from daily conversations and friendships—the six months in Tokyo when for all but five minutes a day, from the time I left home until I returned in the evening,  I heard only Japanese.  During that time I worked on the first draft of the memoir every Thursday, and on Saturday mornings I wrote a weekly “Tokyo Journal”—26 of them. 

I didn’t write that steadily again until I went to Cambodia in April of 2012 and again in January this year.  My weekdays at Sihanouk Hospital were full with rounding and preparing talks; in the evenings at my guest house I kept working on what I would teach the next day. There is not a lot of sight seeing to do in Phnom Penh and weekends were empty.   In Tokyo I wrote in my closed-door office at the University of Tokyo, but in Phnom Penh I wrote in  Brown’s Coffehouse.  Full as it was of expats and NGO workers and trendy Cambodians, writing was surprisingly easy.  I never saw a soul I knew. 

Even before the accident and surgery I had suspected it would be hard to write from the lovely study I have at the Woods Bay house.  Too many distractions, too hard to go off the grid, to close the door and ignore all the work I seem to endlessly—and happily—find in the orchard and gardens and waterfront.   

Writing in a coffee shop seemed to be worth a try.  Brookies is a beloved summer bakery that is trying hard for a genre change (7AM  cinnamon rolls and coffee to late-night country bar).  It has worked out fine—perhaps something of a pilgrimage and no other distractions are what I have needed to get me started writing again.

There are few customers at Brookies, now. The summer rush is now two weeks past—kids have gone back to school or college, the big families with young children now returned to whatever town or city they spend most of the year in.

Today—a Sunday--the road from Woods Bay to Bigfork was mostly empty except for an occasional deer trying to decide whether to commit suicide on my car’s hood. It is still hot during the days—I have been told that this is the third hottest August in Montana history.  But the evenings now cool down rapidly, and for the past few days the temperature at dawn has been flirting with the mid-forties.  I noticed yesterday that in just the past week the poplars and many of the native shrubs have become golden from their summer deep green. 

Yesterday I saw the first flight of ducks heading down from Canada.  The number of hummingbirds in the garden is falling off. 

The latest perennials appeared yesterday, purple asters sprinkled through the fading snapdragons and helianthus and phlox.   The plums have just come in.  There are already a few apples on the ground under grandpa’s ancient trees.

 We have slept under blankets for the past few nights.

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