Rwanda Coming Soon....

Hey Everyone,

this Saturday (March 31) I leave for Rwanda! I'm going to be teaching anesthesia techniques to local residents and nurses for the month of April. This is part of a joint program with the American and Canadian Societies of Anesthesiology. I became involved in this program at the suggestion of a former professor at Stanford, Alice Edler.

For several years, Alice has been taking Stanford anesthesia residents to countries such as Tanzania and Ghana to help in teaching local physicians under sponsorship of the American Society of Anesthesiology's (ASA) Overseas Teaching Program (OTP).

I'll be teaching various techniques in pain management - both acute and chronic. Acute pain is a phenomena all of us have experienced in our lives, and typically follows tissue injury - which includes post-surgical, trauma or an acute disease process. Typical medications for the mitigation of acute pain runs the gamut from drugs as simple as ibuprofen and tylenol to more potent opioids such as morphine and demerol. In addition, local anesthetics such as lidocaine, and it's longer-lasting cousin, bupivicaine, can be quite handy when used to block pain transmission signals along nerves. Nerves can be "blocked" with local anesthetic meds at any point from their origination in the spinal cord all the way to the distal extremities.

The application of local anesthetics typically involves the use of needles to deliver the drug to its site of action. Nerves lie beneath the skin (both shallow and deep) and therefore are hidden from view. Finding them requires a knowledge of human anatomy and specialized instruments. Stay tuned, cause we'll be discussing these instruments later.

Pain becomes chronic when it lasts 3 months of longer, and may or may not involve ongoing tissue damage. Chronic pain is typically much harder to effectively treat than acute pain, and unfortunately, in large section of patients, may never be cured completely. Sometimes the best we, as physicians, can hope to do, is reduce someone's pain enough to restore some degree of function. Improving function can mean being able to take a walk with a spouse, hold a child in your arms, return to work or simply being able to sit in a chair. It is the field of chronic pain the I'll be studying during a fellowship year beginning July '07, at the University of Iowa.

For many of us, the name "Rwanda" conjures images from the Genocide brought to our attention recently in the film "Hotel Rwanda". In the spring of 1994, during a period of only 100 days, nearly a million people (roughly 1 in 10 citizens) were slaughtered along mostly ethnic divisions. The genocide came to an end when the rebel movement, composed of mostly ethnic Tutsi and led by current Rwandan president, Paul Kagame, seized control of the capital city of Kigali.

When telling friends and family of my plans to teach there, several have asked, "is it safe there?" From what I've read, and messages from other docs in the field, the answer is a unanimous, "yes!" It seems as if the people of Rwanda are struggling to simultaneously remember the past, yet move forward as a unified country.

Coffee has once again become an important export crop for the country's growing economy. The tourism industry, know for it's national parks and endangered mountain gorillas, is also on the rise.

A recent surprise discovery to me, is that Rwanda apparently has quite a bicycling community. In fact, local bike component manufacturer, Ritchie has adopted Rwanda for a very enthusiastic outreach program with the appropriate title, "Project Rwanda." The picture here was borrowed from the Ritchie website, showing a young Rwandan lad on his wooden bicycle. Check out more of these great pics here.

This recent news has prompted me to bring along my Surly/Xtracycle made famous right here in the "Chronicles of Mania" report on the Costa Rican Bike Adventure. I think the bike will be a perfect means to transport myself around town and mix it up with the local peeps.

Bike tour in Costa Rica

From the comfort of my home in Berkeley, bike touring in Costa Rica seemed like a great idea. Pack up a bicycle, bring a few a clothes, some sunscreen and a rolling adventure awaits. As usual, the adventure doesn't follow the script, and you sort it out when it's all done. Here we go....


Prologue

I had 2 weeks in a row of scheduled vacation time at the beginning of March, and had already made plans to meet some buddies in Sun Valley for week of back-country skiing. This left the second week open, which I had tenatively planned to spend working on my attic rennovation. When my pal JJ (aka Julian, Jerome, Jay) Grove called to tell me that he had the very same week available, and that he was in dire need of a good vacation from his busy Pain Managmenet practice in Baton Rouge, Louisiana. I couldn't resist the temptation to travel.


He suggested a trip thru the adventure travel company, BackRoads, which specializes in active travel for folks with more cash than time. I'd never taken a trip with BackRoads, but I resisted the idea of having someone else in charge of my own adventure. Having another person plan the whole outing down to the last details, just seemed a bit too scripted for my tastes.

"How about us doing our OWN BackRoads trip?" I suggested. "We bring our own bikes, carry our stuff in panniers, and cruise a route of our own choosing."

JJ was all over it, despite the fact that he later admitted to not knowing what a 'pannier' was. "Just follow my directions," I promised, "and it will be all good."




Day 1-2:

Arrived in Liberia, Costa Rica to meet JJ . After crashing at a local hotel, we awoke to a sunny day and started assembling our bikes. JJ, who openly admitted to not knowing the first thing about putting a bike together, was an enthusiastic assistant. Together, we pieced together my Surly/Xtracycle and JJ's new Gary Fisher mountain bike. JJ decided to give a go at clipless pedals. Those of you who have mastered the use of clipless pedals know where this is going. After a quick breakfast, we loaded up the rigs and headed into the heat of a midday Guanacaste sun.



Afer a few easy miles on good roads followed by a satisfying lunch at a roadside bar, we took a turn south down a gravel road known by the name of "The Monkey Trail." This road could be described by several choice adjectives which include 'rolling, gravely, washboardy, dusty, hot, undulating, and sucker summit.'

Despite of the adverse road conditions, and JJ's occasioanal tumbles into the gravel when he forgot to unclip from his pedals, we remained in good spirits and gradually pressed onward. We finally rolled into the little seaside pueblo of Potrero, covered in a thick layer of Costa Rican dust just in time to catch the sunset over the bay.


Day 3: Potrero to Tamarindo
God bless tail winds.


Day 4: Chilling in Tamarindo
I'm sure at one time Tamarindo was a beautiful, sleepy beach town full of Costa Ricans and the rare Gringo surfer. Today, however, it has become a veritable boom town with all the undesireable effects that happen when Floridians and Southern Californians discover cheap, beachside real estate in a country in which the almighty US dollar goes a long way towards retirement bliss. Most of the local Costa Ricans (ie. Ticos) have since moved inland in search of cheaper housing and make the daily commute to jobs either serving Gringos or building new condos. The animosity is quite palpable.

While JJ kicked it poolside, soaking up the intense tropical sun (coco butter qualifies as sunscreen, doesn't it?), I made a early morning run to the surf with 3 blokes from a local surf shop. The waves were quite good Playa Negra, if only chest high, and we had relatively uncrowded conditions for at least an hour.

Day 5: Tamarindo to Nosara (The Good, the Bad and the Ugly)

The Good: This was my first experience of true bike touring - and by 'true' I mean a completely self-supported ride in which you carry everything you need on the bike. Any additional necessities, such as meals and sleeping accomodations, you just pick up along the way. I discovered that this is a fabulous way to explore a new land! The combination of the pace, the quiet, and the meditative repetition of the turning cranks makes for a very soulful experience. When locals catch you riding by their homes or places of work, they just can't keep themselves from smiling and waving hello.

The Bad:
Costa Rican roads leave much to be desired. All but a few are paved, and despite their small size and rough conditions, many of the secondary roads see significant traffic - including commercial trucking. The hot, dry, dusty roads, combined with a strong cross wind and hurtling trucks creates a terrible dust bowl. The preferred riding technique - one hand on the handlebars, the other holding a hand towel over the nose and mouth. I was wishing I had the foresight to pick up some industrial strength particle masks prior to leaving Berkeley.

The Ugly: There's nothing worse for a healthy sunburn than a fresh case of road rash. After 4+ hours of riding on gravel roads, we had just about reached the ocean for the first time since our 6am departure from Tamarindo. I had just finished descending a long stretch of road and could hear the surf breaking and feel the cool ocean breeze near the town of Logarto. JJ, just a few minutes back, had just begun his descent, when the back end of his top-heavy bike got into some loose gravel and he went down in a cloud of dust. When JJ wheeled up and casually mentioned the fall, my eyes quickly spotted the blood soaking through his surface layer of sweat-caked dirt. We borrowed a local's garden hose and went to work cleaning the dirt from his wounds. JJ spewed a few choice words while I worked the water, and the locals smiled through sympathetic winces.

An hour later, short on water, and feeling the need to get some food, pronto, we hitched a ride in the back of a truck which delivered us just a few miles from the town of Ostional. On the verge of a serious bonk, we plunged into the first open cafe, and JJ promptly ordered 4 fried eggs and 2 orders of toast (wasn't this a scene from The Blues Brothers?). An hour later, rehydrated and fed, we rode the final 10 miles into the town of Nosara, and our final destination. The biking portion of our trip was over!

We spent the next 2 days in Nosara relaxing. Through Steve Ternlund, a friend and colleague in the Bay Area, JJ and I came to meet Heidi and Rick from Nosara Travel. Their shop was our first stop in town, and they immediately diagnosed our exhaustion. Like a loving mother, Heidi took care of us on the spot by booking a hotel for the two nights, arranging dinner plans and directing us to some cool activities (eg. zip lines over the rain forest). We really enjoyed meeting these 2 expats, and hope that our paths will cross soon. Thanks for the morning surf outing, Rick. And for Heidi - Long live the public library!

Check out our short movie!

Lessons Learned:
1. Bike touring kicks ass (and it surely kicked ours). I will definitely plan more trips like this one. But perhaps I'll check the road conditions first.
2. Whatever anyone tells you, do not choose a bike tour as your first outing with clipless pedals.
3. Coco butter has no sunblocking properties.
4. Easier (ie. BackRoads) ain't necessarily better.