I got an email last night from the Wilderness and Environmental Medicine Journal with a link to a recently published Letter to the Editor that I can share for free with friends and family.  They somehow published two manuscripts of Jeremy Joslin (my fellowship director) and mine in the same issue.  It’s crazy how some of my manuscripts have literally been sent to like 5 different journals now, and others are snatched up immediately.  Oh well, better lucky than good.  Hopefully all you ultra-runners and Global Limits alumni will enjoy this mini case report.

Acetazolamide Use in an Ultra-Runner

 

 

I recently got back from a backpacking trip outside of Roanoke, Virginia.  There is a really neat month-long elective held each year in association with the Wilderness Medical Society for medical students, residents, PA students, and other medical personnel.  It was held in Tennessee last year, and I got invited to come down and lecture. The students have a field practicum at the completion of their month that is basically a 3 night backpacking trip with a smattering of wilderness medicine scenarios thrown in.  I was set up to go last year but the camp where they were staying at ended up getting evacuated due to an ice storm and other inclement weather.  So I was pretty excited when I got asked to be a mentor for the trip this year, especially since I have never been to the area in Virginia where the elective was moved to.

I actually got all of my gear together 2 days ahead of time so that I could do the necessary scouring and purging.  I luckily have a ton of backpacker food – I binge-bought it from REI when they were having a big sale because I always need it for the races I travel to and work at.  I recently bought a new backpack which is almost 2 pounds lighter than my previous pack and a bigger capacity.  And I got a cute little JetBoil stove recently that I have yet to try out other than firing it up in my apartment.  So I’m doing what you’re not supposed to do – trying out numerous pieces of new gear on an actual trip where I’m kind of in charge of other people’s safety.  But that’s wilderness medicine right??? Going out there and just figuring it out.  And it worked out pretty well during my fellowship year for me so what’s the worst that could happen….

Spoiler alert: There were no gear mishaps.  Just rain.  And cold.  And mist.  And more rain.  And real world medical scenarios instead of the cheesy hypothetical situations that I was supposed to present to my students.

But I’m getting ahead of myself.  The trip up to Virginia was beautiful!

I met my group of students that first evening so that we could go over the plans for the weekend.  This trip is kind of their final exam for the course, so they were expected to have picked an appropriate route for their team’s experience, planned out their meals, and prepared a first aid kit to bring along.  My group of 6 students had 2 girls who had never been backpacking before.  Which is great!  I love introducing people to the awesomeness that is backpacking, aka having an agenda that includes nothing but hiking all day and eating all day, and then getting to sleep in a cozy sleeping bag outside.  That being said, I was a little concerned that some of the daily mileages were a little ambitious for folks without much experience.  It’s hard to know how much guidance to give, and how much leeway to give the students to just figure out things on their own.  But I figured as long as we were safe, and everyone was okay with coming into camp in the dark possibly, then onward we would go.

It was about 40 degrees the next morning when I awoke at 0’dark thirty and crammed the last few items into my pack.  Our route had us shuttling a lot of cars and while I was waiting to be picked up, I peaked at the weather app on my phone and saw a big nasty goober of rain and possible convective activity heading our way.  The first portion of our trip had us walking up a steep and muddy trail to a ridge line where we would be exposed to the elements until we made it to our shelter.  When we all got together, we had a little group pow wow and the (wise) decision was made to amend our route so that a. We weren’t going to be in an area without any possible shelter when the bad weather rolled in, and b. Our group wouldn’t roll into camp at dark.  I was actually pretty pleased that the group was able to take into account the new information, and adjust the plans accordingly.

And after another hour or so, we were finally on the trail.  I introduced the group to “rolling lead” as we hiked so that we would all stay together and be able to keep an eye on the newbies.  It was slow going uphill with lots of breaks for snacks, but that’s okay, that’s how I usually roll anyway.  It started raining on our slow climb up to McAfee’s Knob.  It’s apparently supposed to be a really beautiful view but all we got was fog and mist.  Still pretty cool looking:

  
After bagels and beef jerky, we continued to head towards our home for the night – Campbell’s Shelter.  We were sooooo fortunate to have a shelter for this evening (complete with a little porch!) because the rain continued throughout the day and evening.  Everyone’s attitudes were great as we set up a tarp, sleeping spots, and outdoor kitchen.  It was such a luxury to not have to set up tents in the rain.  There is no way to not get everything soaked in that scenario and I feel like our morale may have suffered a bit in that situation.  One of our students even managed to get a fire started with wet wood and leaves – I was so impressed.  I will never again underestimate the power of Vaseline soaked cotton balls for their stellar fire starting abilities.  There was a nearby stream to get water from, and the students got to experience the underwhelming taste of iodine or bleach treated water.  My JetBoil worked great, and my foil pouch of food was amazing!  If you haven’t experienced ramen noodles or other highly processed salty food while backpacking, you have no idea just how mind-blowing such simple concoctions can be.  The fog continued to roll in and the woods were super spooky:

One of the girls in our group ended up cutting her finger while trying to cut the bark off of some wet wood.  I think the students must have been inundated all month with pop-up pretend medical scenarios because it took several tries of her saying “Real world guys” before anyone finally took a look at her finger.  Her platypus for carrying water was the perfect device for irrigating the wound, and they had wisely put superglue in their medical kit.  Wilderness medicine at its finest!

I slept like a baby in my down cocoon and morning brought more mist and rain.  Our plan was to backtrack on the Appalachian Trail the way we came, and to either stay at another shelter or set up tents off trail if the rain let up.  As we were packing everything up, I noticed that one our group members didn’t eat any breakfast.  He said he was a little queasy but wanted to press on.  We started hiking and our march was interrupted by a Wilderness Medicine version of hide and seek.  The group got a little far ahead and spread out, so a few of us quick ran off into the brush to hide.  Time to practice some modest search and rescue techniques.  After a lot of whistle blowing and an impromptu game of sardines, everyone was back together, and cursing me for their “learning opportunity.”  A little further down the trail, I noticed that our queasy kiddo went from pale to green to gray.  Not the progression that I was hoping to see.  He wasn’t able to eat or drink anything and I really didn’t like the way he looked.  So our crew was confronted with the real world scenario of how do you decide when to evacuate.  It’s a tough decision.  We weren’t far from civilization so it’s always tempting to keep pushing forward.  But when you have someone hiking with a heavy pack in cold & wet weather and they look a little worse each mile, it’s time to get out.  An unanimous decision was made to walk out to the cars so that our “patient” could get warmed up, get some rest, and hopefully be able to keep down some fluids at least.

We all made it back to the lodge safely.  With everyone promising to keep an eye on our sick group member, I headed back to the little instructor’s cabin.

The next morning brought more rain but thankfully no more nausea or dry heaves.  We all wanted to try and salvage the trip so the decision was made to make a day hike to Dragon’s Tooth.  Despite the soggy weather, it was a really fun hike.  There were some more technical sections of the trail which involved scrambling on the slippery rock.  We once again had absolutely no view of the surrounding countryside, but that did not detract from the trip at all.  I would love to come back to this area again when there is actually decent weather to see what I was missing though.

  

Pizza bagels and s’mores over the lodge fireplace made for a pretty excellent finale to our abbreviated backpacking trip.  I really liked the group of students that I spent a few days with, and I wish them all well.  Most of the kids were 4th year medical students so in just a few weeks it will be match day and they will find out where they will spend the incredibly tough and stressful years of residency.  I hope to see them on some future wilderness medicine adventures.  As for me, it took me an extra day to get home to Orlando because of the terrible weather in the Southeast.  Apparently a tornado touched down about 60 miles away from us.  Yikes.  But no one died on my watch, and hopefully a few people were inspired to continue to live part of their lives in the great outdoors.

So what does life after wilderness medicine fellowship look like?  Pretty awesome!  Now that may be because I’ve decided to take a month or three off of work in order to try and re-charge.  It took me 14 years to get from the start of college to being a board-certified ER doc, so I figured a short hiatus was due.  I also want to give my expedition medicine business some attention in order to see if this is going to be a viable career option.

Nick and I are just about all settled in down in Orlando, FL.  We ran the Disney marathon about 2 weeks ago.  I struggled a bit given that we had just run the Rock N Roll marathon in Vegas about 2 months prior.  But it was a neat course through all of the Disney parks.  Plus my Mom came down to support me!

   
   
I’ve been busy (well, busy is a relative term here….) with my new position as the medical director for Global Limits.  I’m trying to assemble a pool of physicians who would want to come and volunteer at the races.  I’m also going through the medical kit in order to replenish and improve it.  If any readers are interested in coming to one of these races as a physician or even a general volunteer, please let me know.  

And my last order of business has been to try and design some survival kits for both my car and airplane.  I’m usually pretty good about trying to always have at least a rudimentary medical kit with me when traveling.  I figured that I would take it up a notch and create a survival/medical kit.  Nothing more embarrassing than being a wilderness medicine physician who can’t survive an unexpected overnight of car camping because of poor planning…  Now, I am from Wisconsin, so despite my Florida address, I still have an ice scraper along with mittens and hats and fleeces and boots in the back of my car. But apparently the Boy Scouts think that more than those items are necessary.  After lots of time sitting on the Internet, I found that there are 10 survival categories that one should consider.  Insulation.  First Aid.  Nutrition.  Sun Protection.  Navigation.  Shelter.  Fire.  Hydration.  Illumination.  Repair Kit.  So I’m building off of these categories as well as other lists for survival kits that I found online.  This is what I have so far:

  
The two kits have to be slightly different because of weight considerations in the airplane.  I already keep a life raft, 2 quarts of oil, a tow bar, and other essentials in the back of the airplane.  Any thoughts or suggestions?  I would love to hear from people on this one.

Speaking of airplanes, it was a beautiful flight from Wisconsin to Florida on Sunday.  It was a dreary, overcast day over most of Wisconsin and northern Illinois.  But luckily, at just 3800 feet in the air, nothing but beautiful blue skies.  We even were routed directly over Disney on our approach into Kissimee airport.  A perfect flying day!

   
   

After a very long delay, here is the second half of the Cambodia race (and lots more pictures):

4th stage:I was lucky enough to get a solitary morning temple walk again this year.  This place is just unbelievable.

   
    
   
It was a quick drive to checkpoint 1.  We shared the space with a large group of local Cambodians.  They were selling some sort of tuber, but I did not catch the name of it.  

  
It went pretty quickly for everyone to come through.  Then Pavel and I had a hot hike over the hill to checkpoint 2.  I hate to complain given what the runners go through everyday…but goodness gracious was it hot!  

   
 We caught up with the last runner at the front porch of a little house.  The family there was selling cold drinks and it was nice to take a short break.  I could not have been more excited to get to our waterfall camp.  I was looking forward to this all week – SWIMMING!!!  It was great to hop in the river in between foot tapings.  I had forgotten all of the totally ridiculous places set up for tourist photos.  Jenn, Pavel, and I probably spent 30 minutes posing in all of the different locales.

   
   
We were treated to a restaurant dinner this evening by Stefan, the race director.  That sure didn’t seem like “fish” in my stew but it was delicious nonetheless.  It was absolute heaven sleeping under the mosquito net next to the river.  It was so nice and cool.  And the sound of the river was better than any fancy noise machine from the Sharper Image or the SkyMall magazines.  

5th stage:

It was an early morning start in the dark.  One of our runners wasn’t able to participate today due to serious foot issues.  With all of the moisture and trauma to the tissues of his feet, he ended up with something referred to as trench foot.  This is a disease entity that is very painful and involves death of the surface tissues.  The name of this condition refers to trench warfare, and this was a particular problem for soldiers during the winters of World I & II, and the Vietnam War.  The main prevention is to keep the feet clean and dry which is obviously very difficult in the race environment.  After closely tracking the progress of the runner’s feet, the decision was made to start antibiotics.  Spoiler alert: This incredibly determined runner started the final stage and was able to run across the finish line.  Very impressive.

I started the day at Checkpoint 1 once again.  Which was a great choice since the bread man came by on his moped loaded down with gluten-y goodness.  For the low price of $1, you could gorge yourself on 4 mini baguettes.  Awesome.  There was a local boy who was just cooler than school with one of our crew’s motorbike.

   
 
It was a long day in the heat at the finish line.  I was both entertained by and also entertained the school kids while I typed up my blog.  We also had a drone for filming which made for some very excited kiddos.
  
The final runners came into our camp in the dark.  I was grateful to climb into our sauna/tent for bed but I fell asleep with dreams of cool sheets in a luxurious hotel room dancing in my head.  Big finish tomorrow!

6th stage (finish!): 

It was an insanely early start this morning because we had to go to the Angkor Watt ticket booths prior to the start so that we could all get onto the World Heritage site.  The runners were all really pumped up this morning to finish their race.  We had a staggered start so that the runners would finish closer together.  We took one of our team Land Cruisers to the finish.  There was a big political event at Angkor today and we were very lucky to be able to get dropped off at the front due to the heightened police presence.  I think that if you just act like you know what you are doing, other people tend to believe it… As evidenced by our driver and the police at the gates.

It was nice to see some of our runners’ friends and families at the entrance of Angkor Watt.  It’s pretty heartwarming to see that loved ones are willing to travel halfway around the world in order to show their support.  The wife of one of the runners was sweet enough to bring a cooler of cold drinks so that everyone could have some refreshment at the finish.  How thoughtful!  The finish was emotional as usual.  What a big accomplishment!  Congrats!

There was a little time to take in a little bit of Angkor Watt.  And then I had the best iced coffee of my life!

   
    
   
Hotel time!  Arctic A/C and shower time!  Tuk tuk to town time!  Pizza and $1.75 mojito time!  Massages and manicures for $15 time!  Rush to the awards dinner time!  Pub street time!  Another race on the books!

   
    
 
Post-race:

Jenn and I had an extra day and a half in Siem Reap before our respective flights home.  One of our star race drivers was able to arrange a temple tour for Jenn, Laura, and I.  It was absolutely wonderful.  We saw some amazing temple sites and then had a 3 hour spa extravaganza.  It was nice to get a little time to enjoy the local sites and relax before the long trip home.

   
    
    
 Cambodian Starbucks at the Lara Croft Tomb Raider temple:  
A big thanks to Jenn Starling, my co-race physician!

  
So that’s a wrap for Cambodia 2015!  And for my year of fellowship!  After arriving back in Syracuse, I am officially a Wilderness and Expedition Medicine trained physician.  I am so glad that I took the risk of leaving my job to pursue this adventure.  Please stay tuned to my blog for the continuing sagas of my big life.  And please keep me in mind if you are considering any expeditions or remote travel, and feel that you might benefit from having a physician along with you!!! 

Sorry for the delay with the continuation of the Cambodian saga.  I have been trying to juggle a visit at home with the completion of my fellowship with moving from New York to Florida with the holidays.  Here is the first half of the Cambodia race:

1st stage:What a huge difference from last year! At the end of the first stage one year ago, I had 14 very sick runners on my hands and I was wondering who the heck put me in charge! This year was wonderful. The race started with the Cambodian national anthem. Which is apparently the longest national anthem therefore they only played a portion of it. Then there was some chanting by local Buddhist monks. 

   
 The runners were all pawing at the ground, raring to get this race started. The very initial portion of the race begins with a short loop to a local village and then brings the racers back past the start line. It’s always fun to see the initial ranking of the runners as they strut by just a few kilometers into their epic race. I was at checkpoint 2 and it was a quick car ride over smooth-ish red sand roads. Laura and I manned this pit stop for the runners. It was right in front of a tiny local shop and the owner was kind enough to lend us plastic chairs and kept the cooler full of cold-ish coke. The red plastic chairs were quickly snatched up by the village children and we were left inching our way from shady spot to shady spot. I didn’t have the heart to kick the kiddos out.

   
 The runners started coming in quickly. The full effects of the heat hadn’t quite caught up with everyone yet and most spirits were high. After we closed up shop, it was on to the finish for me. Our accommodations were provided by a small village. There were several homes which had cleared out their top floor for Global Limits. Everyone looked great as they reached the finish line and it was a fairly relaxing evening in camp. A bored race physician is a happy race physician… 

   
 Jenn and I opted to sleep in hammocks again owing to the intense heat of the upper floor and got some help setting them up underneath the house. I got the dinner sweats bad while eating my dehydrated meal. I felt totally crazy until Jenn admitted that she got them too. We were able to use the house’s washroom. I still don’t really understand how to get clean with just a bucket of water. And how do you wash your hair??? I spurted and sputtered under the bucketfuls of water that I dumped on myself but I don’t know how much my cleanliness improved. That’s okay, you get a new layer of sweat and dirt mere minutes after stepping outside so it wasn’t like my overall lot had changed all that much. The family with whom we were sharing an adobe had an affinity for Western music. It was surreal to be hearing Adele and Imagine Dragons in an incredibly remote Cambodian village. Just one of the very cool moments to be had while traveling. My swaying hammock lulled me to sleep quickly however my reverie were broken at 3am to a cacophony of village dogs. They were either having a party, or having a fight, but either way it was quite the ruckus. Then shortly after them the roosters decided that it was time for everyone to be awoken by their raucous cries. But then the dogs didn’t want to be left out of the fun so they started in again. This continued until I couldn’t take it anymore and finally decided to start my day at 4:30. I had totally forgotten about this early morning scene from last year but I’m almost positive that things had gone almost exactly the same way last year. Oh well, life could be a lot worse.

2nd stage:

Okay, things are starting to derail just a bit. Instead of getting acclimated, it seems like the heat is catching up with the runners. As mentioned earlier, the day started prematurely. I jumped in our race car just prior to the start so that I could get over to checkpoint 1. We opted to have the checkpoint just before the bridge where it was technically supposed to be located in order to have a little shade for our runners. I started to see some runners with nausea and vomiting – now this is starting to feel like Cambodia… After the checkpoint was closed, we slowly made our way to the finish. We stopped by each subsequent checkpoint for a little chat and visit. The finish line and camp are amazing! Even though I had seen this same site last year, it was not any less impressive. A row of tents lines the final few meters of the race course with a looming and decaying temple as the back drop. Indiana Jones was filmed here (awesome movie by the way).

   
 I got a chance to stroll around the entire site and marvel at the temple structures that seemed to grow right out of the unkempt grounds. I think the temple actually looks cooler when it is in ruins. These are the kind of scenes that you think only exist in movies but then when you actually stumble upon them, it just kind of stops you in your tracks. 

   
 The runners slowly trickled in and everyone was looking really great. There were some minor foot issues but I was so pleased that the runners were all genuinely interested in learning to take care of their own blisters. I think it’s a great skill to have if you are a distance runner. You know what they say, teach a man to fish… 

   
   
I had taken care of a runner at the first checkpoint who had unfortunately stumbled within the first bit of the race and struck her face. Jenn and I were just getting ready to figure out the best way to safely and cleanly put her back together when I got the call that a runner was found down out on the course. Jenn put in a suture and cleaned the rest of the runner’s face up – and had absolutely phenomenal results!  So good that we are planning on writing up a case report about wound care in the wilderness.  One of our local drivers is incredibly helpful and jumped right into his Land Cruiser to take me as far into the jungle as possible. By the time we caught up with the runner and our volunteer (who happens to be a doc), they looked much better. After a brief check, the runner decided to continue on. Everyone made it in safely and we only had one DNF. Half of our team had to leave tonight in order to be able to man the checkpoints in the morning so I was manning the sick bay on my own. No major issues though and I spent part of the evening sweating my you know what off while eating dinner in my tent. The mosquitos and ants were so irritating outside that I finally gave up. It was so dark and so quiet out at this remote site that I had a really good night’s sleep. The long day is looming ahead in everyone’s mind.

3rd stage:
My day started off with a cup of tea and I treated myself to strawberry granola with powdered milk for breakfast. I feel like those instant oatmeal packs keep me full for exactly 20 minutes and then I want to eat every single snack that I have in my bag. We had a staggered start this morning so the slightly slower runners started an hour before our slightly faster runners. Today is going to be a looooong day. The best estimate is that the final runner will not make it in until 11pm. I stayed behind in camp until the last runner was well into the jungle, just in case someone had to turn back or get evacuated out. I felt really fortunate to get to go into a tiny village nearby and enjoy a coffee. Having a coffee in the smaller villages is a neat experience. The coffee itself is super strong and super sweet. And you get to sit in a teeny tiny restaurant with a bunch of the local men who are sitting there with their respective coffees and cigarettes. I know this doesn’t sound like much, but sitting in that setting watching the village life swirl around you is an experience to be had. 

   
 Once I got the all clear from the boss, we started the 150 km car ride to the finish. It was quite nice to get about 3 hours in the air conditioning. There is a touristy town right in front of the temple so I was able to have cold fresh coconut water and fried rice. Sweet! I seriously cannot believe how hot it is today. I hope the runners do okay out there. It is a long straight road in the sun to the finish. We have several cars going back and forth with our staff in order to check on the racers more frequently. Calls started coming in about runners dropping out. We had 2 earlier in the day who got a tractor ride out of the jungle, and a third a little later. The heat was really taking its toll on people. Several hours at the finish yielded just a few people coming in. There was quite a lot of time between runners. We had someone come in who really didn’t look well. Thankfully she cooled off gradually after wetting her down and fanning her off and after about an hour was able to sit up and start re-hydrating. Most folks looked exhausted and extremely hot but oddly perky. I guess they were just relieved to be done. I can’t imagine spending that kind of time in the heat. The bright sunny day turned into a very buggy dusk but still the heat continued. I think this may be hotter than last year. I think it was overcast on the long day. But I don’t know, either way, it’s hot, damn hot (for those of you who have seen Good Morning Vietnam, I hope you find this weather report humorous). 

   
   
Once darkness set in, we got word that another runner had dropped out but still no other finishers. I was getting eaten alive at the finish line so decided to move one of our tents to the finish so that I could read my kindle in bug-free comfort. We finally got down to the final few runners. I was able to run into the small town opposite the temple in order to grab some dinner. As soon as I got there, I started seeing head lamps bouncing in the dark down the road. It’s ironic how I sat for hours and then the moment I try to get dinner, people start coming in. I like to check all the runners as they come in after a long day like that.  I was able to check some of our runners out on the road before they made the turn into the final stretch. My daily coke was excellent and the food was pretty good too. I opted for the cashew chicken since I had seen cashew nut trees on the drive earlier. The other volunteers also slowly trickled in and soon they were 3 of us sitting in the finish line tent. The last runner walked across the finish line around 10:30pm. It was nice – all of the volunteers were at the finish line when he came in. What a long day. Before bedtime, everyone looked foot weary but ready to face another day. 

Jenn and I walked a little ways away from camp to set up our hammocks. While we were doing that, two local guys came over to help us hang our hammocks. Apparently they were not impressed with our knot tying skills. But then they set up right by us too and they were some of the most impressive snorers that I have ever experienced. The one guy sounded like he needed to be on a CPAP machine. He was snorting and grunting and spurting and sputtering. And there were somehow roosters and dogs around the temple grounds. But luckily the animals got it out of their system by midnight and I got about 5 hours of sleep. Another long stage over.

  

It’s hard to believe that I am back in Cambodia. It’s like I was just here. I was a little nervous as usual when touching down when thinking about getting all my medical supplies through customs, etc. It was incredibly easy to get through immigration and customs thankfully. The Cambodian air hit me like a wet blanket when I stepped out of the terminal. I had to wait for one of the runners but soon we were piled into a careening tuk tuk with 3 large pieces of luggage. 

   
 The Himawari hotel was very nice as usual. I had about 20 minutes to shower and get situated before our first team briefing. It was business as usual at the briefing. Afterwards there was an unexpected treat though. Fireworks! Apparently today is the Water Festival in Phnom Penh and fireworks explode over the Mekong River in celebration. The race crew was headed out to dinner but I wanted to wait for my co-worker. My fellow race physician is Jenn Starling, of Grand to Grand fame. 

  
I was trying to wait for her to get in before joining everyone for dinner but promptly fell asleep. A little after 8 we were on our way to a small local restaurant. I can never get over how cheap things are here. Our meals were about 4 dollars a piece and drinks were even cheaper. The power went out mid-way through dinner which was interesting. But the staff seemed to expect this event since candles were set out within minutes of the blackness settling in over us. I pooped out quickly after eating and we headed back to the hotel to start sleeping off some of the massive jet lag from the 38 hours of travel.  
2nd pre-race day: We got to sleep in a little this morning. There was nothing going on race related until 3pm, so the day was my own. After breakfast in the hotel, we divvied up supplies in the medical kit. I had packed my personal kit this time so it was quite the relief to have everything organized and already know what was what. We then ventured out into the bustling metropolis of Phnom Penh. We visited the museum. Last year during our city walk, we visited the courtyard of the museum but did not get to go inside. It was pretty neat – I think that the photographs on the walls of local vistas were almost more ascetically pleasing than the stone carved relics. 

   
 Laura took us to one of her old favorite Vietnamese restaurants (Laura spent 8 years living in Cambodia previously). We had these really interesting giant savory pancakes with what looked like entire gardens of greens on plates. There were about 50 different little dishes of sauce too. They were excellent! As I’ve mentioned before, I think part of my love of travel stems from my love of eating. And this place was right on the mark.

   
 We then visited a Cambodian pharmacy which was a little like being a kid in the candy shop. If these kinds of places existed in the US, they would put American physicians, urgent cares, and ER’s out of business. What I am trying to say is that you can pretty much just ask for whatever drugs you want there and they just give it to you. Crazy! It’s nice to be able to get some drugs locally because despite all of the appropriate paperwork, I am still uncomfortable with bringing “the strong stuff” across the border. Eventually the time for us to get to work rolled around. We checked all of the racers in and thankfully there were no surprises from a medical perspective this time around. Check-in rolled right into the banquet. The local racers were recognized before dinner as well as a few Global Limits repeat offenders. It was nice to catch up with a few racers that were in Bhutan. Bedtime felt pretty awesome though too. We head out into the jungle tomorrow morning.  

3rd pre-race day: We had an early check out at 7:30. The racers had the option to take a city tour but I took said tour last year so I spent the extra hour drinking coffee and eating chocolate croissants at the hotel breakfast buffet. It was quite a long and dusty bus ride to our first camp.  We had a few interesting stops though. The first was the “spider market.” We stopped there last year as well. For a horribly arachnophobic gal, it wasn’t like the best thing ever but it was still cool to see again. All kinds of fried bugs, larvae, and spiders glisten in their oils in the noonday sun. Little girls tried to press bags of bananas in your hands for the equivalent of about one US dollar. 

  
We were then whisked off to lunch. It was in a new venue this year and was quite nice. I think I may have been most impressed with the actual sit down toilet and toilet paper! Quite the luxury. We rolled into camp around 3 in the afternoon. Everyone slept on the floor in a large temple. I think it’s impossible to capture how neat it was inside with the mosquito nets and the gaily painted walls but hopefully these photos give you the general gist.

   
 Jenn and I set up hammocks underneath the structure. I’m so glad we brought them! It was at least 10 degrees cooler outside. And there was even a bit of a dry breeze. I busted out the first backpacker meal of the trip and tried to stay awake until a reasonable bedtime. Unfortunately I didn’t make 8 o’clock but I guess there’s always tomorrow. I am obsessed with sleeping in a hammock so it was with great glee that I climbed in. 

  
I woke up in the middle of the night to use the bathroom (of course) and it was quite the creepy experience. There was a very bright moon half hidden in the clouds and my walk to the toilet was guided by torches. This could have potentially been a pretty romantic midnight stroll. However my reveries was interrupted by the rushing whooshes of wings on the night air. Large wings. I looked up and there were bats! Huge bats. I scurried to the WC and back with visions of being mauled by bats in my head. Or bats tangled in my hair. Or what about vampire bats! Goodness. Suddenly my beloved hammock seemed like quite flimsy protection against the creatures of the night. Thankfully I woke up to all of the runners banging around in one piece and without any extra puncture marks on my body.

   
 

  
Well here I am- on another airplane, another trans-continental flight, another bout of packing up 2 weeks worth of personal goods and medical supplies, another obsession over what is going to be the most comfortable thing to wear for 40 hours straight, another realization that I forgot to get that one item that I keep writing down from one trip to the next, another melancholy farewell to my incredibly supportive boyfriend, another willful avoidance of getting into that conversation that is one step beyond small talk with the slightly weird stranger beside on the airplane, another American holiday spent at 30,000 feet, another knot of excitement and anticipation and trepidation in my guts, another pre-travel day spent putting my favorite snacks in mini ziploc baggies and charging every device known to man…. but most importantly, another adventure! Another chance to step outside of the status quo and get to pursue something fun and exotic and challenging rather than accepting a 9 to 5 existence. I was not built for routine or permanence. And I am so freaking lucky to not only get to call myself an Emergency Medicine physician but a WILDERNESS AND EXPEDITION doctor. How cool is that? Going to crazy places and using all of my training to think on my feet is actually my paying job.  

When I return from Cambodia (that’s where I’m headed now by the way, for the annual Global Limits race – Ancient Khmer path), I will be done with my wilderness medicine fellowship! And I just got a big time job promotion/opportunity – I have been invited to be the new Medical Director for the Global Limits series of races. Meaning that I am now in charge of three international races per year. Despite other stressors in my life, I am pumped. I was so unhappy with some aspects of my last job. But then I took that discontent and turned it into the impetus to create a career (and big life) that is all my own. I don’t know if I will be able to make a living out of being a wilderness medicine doctor but I’m sure as hell going to try. And I’m a lot closer to it now than I was a year and a half ago.  Stay tuned for my documented attempts at living the dream. And there will also be full coverage of this race coming your way.

On a less thoughtful note, here are some amusing photos from my travels thus far.

World’s smallest beef jerky pack from the airport in China (I feel silly for wasting so much money on packages of it for this race – if I had only known…..)

  
Guangzhou Airport terminal and lounge:

   
 
And I thought that I wouldn’t be able to get decent pizza until I get back to the States in 2 weeks:

  

Nick and I are back from Las Vegas (well he is already out on his next adventure – ferrying an airplane from Wisconsin to Arizona), and are proud marathon finishers!  We just squeaked by, and beat our goal time by a 44 blazing seconds!  As I mentioned earlier, this was Nick’s first marathon.  It was pretty special that we were able to train for this race together and then cross the finish line side by side.

  
The race started out on the Vegas strip with a Kid Rock concert blaring.  The first few miles just flew by.  This particular race has the half and full marathon runners all start at the same time so at times it was a little frustrating to see all of the half-ers fly by us.  But I also felt some pride in the fact that we had signed up for the whole enchilada distance.  It was so cool to run by all of the different hotels on the strip.  The massive scale of the different resorts became apparent as we ran.  It was over 4 miles from one end of the strip to the other!  We ran through Old Vegas too, and then out and around some random suburbs and industrial areas.

There were a number of bands and DJ’s out on the course to keep the energy going.  I felt like I could run forever – we even skipped one of our planned walk breaks.  The long training runs we had been doing actually seemed a lot longer than the race.  I love being out there with all of the other racers and the spectators.  And it’s really neat to see all of the hours of training and effort pay off on race day.  I’ll get the chance to do it all again shortly since I’m also signed up for the Walt Disney World marathon in January.

  
For our celebratory dinner, we went to The Golden Steer.  It was amazing!  For anyone who loves an old school steakhouse or even a Midwest-style supper club – I highly recommend this place.  Don’t let the outside fool you… Once inside, it was all dark wood, red leather booths, and tuxedo clad waitstaff.  Anyone who knows me, understands my great love of finding both the big and small occasions in life to celebrate.  This was a big event in my big life with a great big steak dinner celebration!

  

Well,  after 16 weeks of training, the day is almost finally here.  The Rock N’ Roll Marathon is on Sunday at 4:30pm.  We will be in the slow people corral but are super excited about running Nick’s first marathon.  And are hoping that the dozens of Gu’s, long weekend runs, boring treadmill miles, and hours of practicing yoga with the world’s tightest hamstrings are all going to pay off.  Nick and I got into Las Vegas yesterday evening and proceeded to do just about everything that you aren’t supposed to do right before a big race….

   

We are about to go on our last little run and then pick up our goodie bags and bibs from the Expo.   Stay tuned for my report from the race.  And please feel free to leave comments with any last minute advice or words of wisdom!

   
(You know me, I’m always a sucker for beautiful flying pics) 

  
 

I just got back from an awesome trip to Spain!  I have been kicking myself for not keeping a travel journal while I was there since I’m sure that I forgot a ton of details.  But I will try my best to recreate my epic trip to Northern Spain and Madrid with my best friend, Danielle Dragoo.  

  
This trip started when it turned out that a Brazillian Visa is a bit harder to come by than one would initially think.  I was scheduled to fly to Brazil for 12 days to work at the infamous Jungle Marathon.  It’s supposedly a pretty wild ultra, multi-stage race that takes place deep in the Amazon.  I was really looking forward to this race given the interesting stories that I had heard as well as my recent devouring of a riveting book about an explorer consumed with his quest to find a lost city in the Amazon (“The Lost City of Z” by David Grann, amazing!, find me on goodreads if you are interested in what I am reading…).  Due to an unfortunate series of events, I was less than 3 weeks out before I was supposed to leave for the race and still did not have finalized travel plans.  Long story short, Brazil does not offer an expedited Visa service, and I was ultimately Visa-less on departure day.  Danielle had given up on the Visa quest too and we found ourselves with 2 weeks off of work.  Since I’m never happy unless I’m running around at 100mph with my hair on fire, furious plans started forming.  I had heard about the Camino from a runner in Bhutan and thought it might be the perfect combo of outdoorsy trekking with some luxury and adventure thrown in.  Danielle found a company that would make all arrangements for us, and a quick email to my travel guy, Steve, afforded us plane tickets.  Just days later… we were off!

For those of you who haven’t heard of the Camino, here’s a little background.  El Camino Santiago is most popularly translated as “the Way of St. James”.  This is slightly misleading as there are several different Camino routes that one can take.  The end point of all of them is the Cathedral of Santiago de Compostela in Galicia where the shrine of the apostle St. James exists.  Tradition has it that the remains of this saint are buried here.  St. James was one of the 12 apostles, and the first to be martyred.  Legend holds that St. James’s remains were carried by boat from Jerusalem to northern Spain.  The Way of St. James was one of the most important Christian Pilgramages throughout the Middle Ages.  In current times, over 200,000 people per year set out across Europe in order to find their way to Santiago de Compostela.  Although many still view it as an important pilgrimage within their Christian faith, other hikers walk the route for spiritual purposes or even for pure physical adventure.  There are a lot of great books out there as well as information on the internet if you want to learn more about the Camino itself.  We choose to do a small portion of the Northern Route:

  
After a stopover in Madrid, we started our journey in San Sebastian.  It is a gorgeous, smallish city on the coast.  There is a lovely half-moon beach which seems like it is trying to hug the ocean waters into the city itself.  The company we booked with, Caminoways.com, had made all hotel arrangements for us and would also be transporting our luggage from one city to the next.  The first hotel choosen for us is clean and neat, and also in a central location.  So far, so good…  We found a neat district of town with narrow cobble-stoned streets and lots of good bar/restaurants.  We stopped to sample little sandwiches at a tavern but were horrified when the workers tried to exterminate the resident cockroaches right in front of our eyes (and mouths and stomachs!).  We visited a pretty church and after more strolling, ended up with a bottle of local wine and huge skillets of paella.  We made the decision to treat ourselves to one “treat” a day and wasted no time finding an adorable little bakery.  Tomorrow – the Camino!

   
    
 
Stage Uno – San Sebastian to Getaria – 25 km

We’re off!  It seems exciting to have nothing to do today but walk.  And catch up more with my best friend.  We walked to the beach where we picked up the yellow arrows and scallop shell symbols that make up the markings for El Camino.

  
We almost got lost less than 2 miles into our journey but a kind soul pointed us in the right direction.  A steep climb ended in beautiful views of the city.  After walking for about 6 hours, we had lunch in a small square within the town of Orio.  Salad, chicken, and fries have never tasted so good.  Maybe it was owing to the freshness of the food they served in Spain but all of the food was incredible flavorful.  At Zarautz, we opted to take off our stiff, heavy, and not quite broken in hiking boots (oops) and walked the last 3+ miles of the day in flip-flops.  I ended up walking the rest of the route in either minimalist sneakers or my beloved Rainbow flops.  My bestie had some blisteres by the end of the day – thank goodness for Rock Tape!  Danielle became a toe-taping expert and hiked every day without compalint.  We could see Getaria from Zarautz, and wound along the coast to our destination. We were foot sore and weary when we entered Getaria, but also elated.  We were greeted with a quaint coastal hotel and spoiled by a balcony overlooking the ocean.

   
   
Stage Dos – Getaria to Deba – 17.7 km

I was super pumped to get up and walk another day!  A very sweet older woman waited on us for breakfast.  And her huband gave us a hard time for not finishing our plates.  What am I, at my grandparent’s for breakfast?!?  It was very endearing though and was a nice start to the day.  I don’t know why coffee everyhwere else in the world is so much better than that in America but I try to enjoy it as much as possible when abroad.  We walked out of town and started our trek to Deba.  We had decided on taking an alternate coastal route which was supposed to be much more challenging but also more scenic.  There was a roadside coffee stand early during our walk where we had excellent mini paper cups of espresso.  After a wrong turn, much guide book referencing, and some backtracking, we were on the coastal route.  It wasn’t well marked and several forks in the road left us worried about being lost.  The skies also decided to open up and we were out wandering in the grey, cold, wet Spanish countrside.  It looked like our trail was going to dead-end at soemeone’s private residence when lo and behold – there was a sign!

  
A singletrack led steeply down to the coast.  We ended up at one of the most incredible and unusual beaches that I have ever seen.  And it was 10-times cooler to be there with the rain blowing sideways and subsequently our privacy.  Jagged cliffs fell straight into the surf.  Gorgeous striped rocks and sea glass littered the beach.  

   
    
 
The rain made the dirt track ridiculously slick and we alternated between struggling up or sliding downhill and cursing while we trudged through the prickers.  It sounds miserable but I was actually having a blast.  The final stretch to Deba had us walking through farmer’s pastures where we were met with the indifferent stares of the cattle and menacing barks of the local dogs.  We stopped to get our treat once we hit Deba and ended up having a really neat experience with some local women in the pastry shop.  They laughed at our soggy appearance and then rushed to tell us how to order our coffee and what the best pastries were.  Very heartwarming.  Our hotel was right on the beach with another ocean-front balcony.  Despite having a toilet on the fritz, the hotel was wonderful.  We hung up our clothes to dry and collapsed into bed.

  
Stage Tres – Deba to Markina – 23 km 

We awoke to grey skies but no rain.  After another hotel breakfast buffet, we were headed away from the coast.  Unfortunately I don’t remember a ton about the walk this day but will insert a few pics below.  We actually stayed a few miles out of town this day, and due to our propensity to take our time on the trail, arrived at our inn just as the sun set.  People in Markina looked at us like we were insane as we walked through town with our packs, muddy pants, and flip flops.  Through all the hiking and awkward situations and meals shared, Danielle and I were just having a blast.  I am so lucky to have a friend like her.  She is kind and funny and strong and so generous.  

   
   
Stage cuatro – Markina to Gernika – 25 km

A steep paved downhill from the inn started our hike today.  We wound through thick forests and past many tiny villages.  Unfortunately the final portion of the walk was right along the highway into Gernika.  This was the only portion of the Camino that was less than scenic.  As we entered town, Danielle found an outdoor clothing store and was overjoyed by the opportunity to buy new hiking shoes.  Our hotel was very nice, and was a spotless oasis to chat and clean up in before dinner.  So far, our booking company has been wonderful!  Dinner was arranged for us at a local restaurant where we took the opportunity to devour an entire plateful of their special Iberian ham.  Steak and fries were surprisingly delicious.  Danielle shared her steak scraps with a tiny Yorkie dog that was dining at the bar with his owner.  We had ice cream cake for dessert which they doused in whiskey.  Awesome.  The food and wine have been so good here!  I think the local food and drink make up a good portion of the enjoyment that I get out of travel.  I also love how tasty and satisfying food is when you have been out and working hard all day.

   
    
 
Stage cinco – Gernika to Lezama – 21 km

I’m already getting sad thinking about the end of our trek.  I love waking up every morning knowing that I get to walk all day.  This was such a great idea for a vacation.  I definitely want to come back some day and walk the final section into Santiago.  

We walked out of town past a beautiful cathedral and city park.  We stopped to dine in a medieval village and had our only upsetting/disappointing encounter of the whole trip.  Apparently the locals in this particular village did not like Americans which they had no problem telling us.  We wolfed down our fixed price menu and got the heck out of there.  Our walk ended with a fizzle at a nice appearing hotel on the outskirts of a down and out looking town.  After a comedy of errors with our non-English and Spanish speaking hotel owner, we finally checked into our room.  Dinner at a local restrant was a total pleasant surprise.  The bartender had just honeymooned in Memphis due to his love of jazz music, and couldn’t have been nicer to us.  The calamari was incredible and he brought us a local liquer to sample.  It was nice to have dinner turn around our poor lunch experience.

   

 
   
 
Stage seis – Lezama to Bilbao – 14.7 km

It’s our final day of walking – I’m sad.  It was a quick hike up to a saddle where we had views of both Lezama and Bilbao.  We took our last set of Camino selfies.  The path to Bilbao was downhill and through a series of public spaces.  It’s amazing how many people in Spain are outdoors and active.  It was neat walking into Bilbao.  And sweet relief to walk up to our 4 star hotel.  After checking in, we broke our vow of “no more walking” and hit the town.  We visited the Guggenheim museum.  Its outdoor beauty far surpassed the works inside.  We enjoyed lots of people watching including during our obligatory afternoon coffee break.  Tomorrow we can sleep in (!) and then on to our final stop of Madrid (again).

   
    
 
Here’s our stats for the trip ( I wore a Garmin GPS watch while hiking):

84.85 miles hiked

13,351 total feet of elevation gained

Madrid

A quick flight landed us back in the Madrid airport.  It seems like we were just here.  I can’t believe how quickly the trip went.  We stayed at Hotel Opera in the center of the city.  We were surprised to learn that the next day was a national holiday and that everything (shopping included – go figure) would be closed.  We saw as much of Madris as we could over the next two days – exploring the many plazas, sampling tapas restaurants, and tearing up the limited shoping.  We spent our last evening in Spain at a flamenco show.  What a great experience – this is an intense and crazy style of dance!  Lots of dramatic hand gestures interrupted with turbo stomping around the stage.  I loved it!  It was very different than the last dancing show that Danielle and I went to which was the Tango in Argentina.  We stumbed upon the opportunity to tour the palace on our walk home.  It was open to the public for free because of the holiday.  The following morning found us on a plane back to the States.  I don’t think I could have had a better experience with my best friend.  I’m so thankful that we were able to have this wonderful adventure!