The Dash Point Pirate

Harvesting Mussels on Hope Island

I’ve only started foraging for shellfish around Puget Sound. Eventually I’d like to explore all of the designated harvesting beaches in the area. It gives me yet another reason to get out and paddle, with the added challenge of trying to arrice at my destination at the right time, when beaches are exposed at low tide.

My diet is normally entirely plant-based, but I will eat a small amount of wild foraged shellfish a few times a year. Oysters or mussels are simple organisms that are most likely not sentient and don’t feel pain. Harvesting them also poses very little environmental impact. Because they are filter feeders, oyster farming actually improves water quality. An annual shellfish and seaweed harvesting license costs a little over $16 when you purchase it online. Refer to the Washington State Department of Fish and Wildlife Harvest Rules. Mussels can be harvested from salt water year round, up to a limit of 10 lbs/day.

 

Mussels cooked with a little white wine, garlic, and Earth Balance.

I also always refer to the Shellfish Safety Information site for beach closures due to pollution and biotoxins. Not surprisingly, the areas around Seattle and Tacoma are typically closed to shellfish harvesting due to pollution. Biotoxins such as the one that causes paralytic shellfish poisoning (PSP) can even occur in the San Juan Islands, despite the much colder water and strong currents. The risk of PSP varies depending on the species. Mussels accumulate the toxin faster than other species, so it acts as a good indicator species. Clams accumulate the toxin at much higher levels and take longer than mussels and oysters to clear the toxin. Concentrations of PSP usually start going down in October and November, but clams can still be toxic an entire year after an algae bloom. This is important to know because some beaches on the Department of Health map appear to be closed (indicated by the red color), but they are actually only closed to clams and are still open for mussels and oysters.

The island caretaker's house.

Hope Island is one of my favorite destinations in the South Sound. It has pristine beaches but is easily accessible from Boston Harbor north of Olympia. I discovered yesterday that it is also a good site for finding mussels. Beds of mussels are located on the south east gravel beach right next to the entrance to the park. These are the smaller Foolish mussels (Mytilus trossulus), and only grow to 3 inches long, as compared to the larger California mussels (Mytilus californianus) you find on the coast which grows to 6 inches.

The put-in is the public boat launch at Boston Harbor. The boat ramp is right next to the marina building. There is free parking right next to the boat launch for people with kayaks and canoes, and restrooms with flush toilets across the street in the parking lot. Boston Harbor Marina is a full service marina which includes a grocery store and kayak rental.

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The distance to Hope Island is 2.85 nm, 7.11 nm round trip including circumnavigation of the Island.

Before going, check the currents in Dana Passage.

 

SUPping at the Northwest Paddling Festival 2013

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If there is one take away message from the Northwest Paddling Festival this year, it’s that stand-up paddle boards are hotter than ever! The variety seems to be growing, with more manufacturers joining the game and coming up with more designs, including the faster racing displacement-type hulls with the piercing bows, and inflatables. Prices have gone up too. High end, lightweight and fast boards made out of exotic composites have pushed the upper limit way up. And it’s not as easy to find a decent, cheap, used SUP on Craigslist anymore either.

Everyone loves SUPs! They are great for dogs! And kids! Personally, I am attracted to the simplicity of being able to carry my board under my arm to the water and going for a quick paddle, without bothering to put on a sprayskirt and drysuit. Who needs it? Especially during an unseasonably warm day like we had at the Festival (82°F!) And as far as wearing a PFD goes, I got plenty of floatation leashed to my ankle! No need to practice wet-exits, complicated self-rescues, or learn how to roll. That makes it a lot easier to learn than kayaking (but also less satisfying, I might add).

Still conspicuously absent were any homemade wooden paddleboards. Katya and I brought her cedar strip board and set it down on the beach to show it off. We were mostly fishing for compliments before we went off paddling in the lake, but it was also part of an experiment I wanted to conduct. I’ve developed a hypothesis, that certain people are simply blind to wooden boats. I think it falls outside of their perception. It's like they are presented with information that just doesn't fit into their worldview and they don't know what to do with it.

The blindest demographic of all seems to consist of attractive young women, especially ones wearing bikinis. They are like the kittens in the classic 1970 Blakemore and Cooper study, where scientists raised kittens in an experiemental environment consisting only of horizontal stripes. They kittens grew up completely blind to vertical lines and when removed from the experimental environment, kept running into chair legs. In contrast, older people are more likely to see and comment on a wooden board or kayak. The demographic most likely to stop and admire a wooden board appears to consist of older men, especially the ones with a lot of facial hair and a background in engineering. Our observations at the Paddling Festival provided overwhelming support for this hypothesis. If you happen to own a small wooden boat yourself, I challenge you to set it out on a crowded beach one day and see what happens for yourself.

 

Other Festival highlights:

• They were giving away free SealLine dry bags next to the transparent EddyLine Journey. I picked up a 5L bag!
• The SUP on-land simulator.
• The Dragonboat.
• The native Salish canoe.
• The Aquaglide Multisport 270 compact inflatable sailboat. When you have arrived at your destination, you can use it as a mattress!

Of course the coolest thing of all was the SUP Buddy beverage holder for your SUP. Katya and I had first heard about the SUP Buddy from its inventor, Devin Carroll, at Urban Surf across the street from Gasworks Park in Seattle, and we ran into him again at the Festival. Elegant in its simplicity, the SUP Buddy actually has proven to be amazingly versatile: Devin uses it in his shower not only to hold on to his beverage but also to give him a place to hang his wetsuit, for instance. Check out our interview with Devin in the video.

Pic of the Day

Dubside dropping the base.

Happy Ripples

Katya on the beach in Pangasinan.

Between the two weeks we spent at Baguio General Hospital, we had a free weekend to relax and explore. Our group hired a couple vans to take us to a resort located on the beach in the neighboring province of Pangasinan. We left Friday evening right after work, driving only about an hour and a half down the winding mountain roads and through small villages in the lowlands to get to the water, the Philippine Sea. We arrived just as the sun was setting. After checking in and unloading our bags we gathered for drinks in the open air bar, which sat on the roof of a small building right on the beach. They had cold beer and buko (young coconuts) waiting for us, and we were treated to stunning views of the sun setting across the calm ocean.

The resort, called Happy Ripples, is owned by Shirley’s (the mission coordinator's) brother. It is right off the main road that runs along the shore, just north of the small town of San Fabian. Besides the beach, it offered clean air-conditioned rooms with showers, a pool, karaoke, and massage services that went on all day long. You had to get your reservation in early because everyone in the group wanted at least one massage a day and I think some people were able to get in two. Katya and I were probably the last people to sign up and we had to schedule for the leftover spots that started at 9 in the morning. Personally, I don’t understand the attraction of having a massage. I can name at least a couple more things I find more relaxing than a massage (that don't involve drugs) including sitting in a natural hot spring after a few days kayaking in the Canadian wilderness and savasana after a good yoga session.

The warmth of the lowlands was a welcome change from cool weather in Baguio, where I would often put on a fleece jacket to walk to work in the morning. Swimming in the ocean was a real treat too-- as warm as bathwater. A few of us including Katya couldn’t wait until the morning to take a dip.

Cattle graze around the brackish pools just above the beach.

Katya and I wanted to get up early to photograph the fishermen on the shore. The beach was wide and flat. Although the tidal range wasn’t more than a meter, there was a noticeable high water line where all the plastic garbage collected. Shoes were a common finding, and Katya ended up with a impressive photographic series of old shoes.

The fishermen here use small boats known as bancas, which are traditional filipino outrigger canoes. They range in size from 10 ft long one-man, human-powered canoes to boats 45 ft long with inboard diesel engines that can carry several people. They all follow the same basic trimaran design and wood construction. The bottom of the main hull is carved out of a large log, and the sides are constructed from plywood. Bamboo is used for the for the amas (outriggers) as well as the akas (the parts of the frame that connect the main hull to the outriggers). One boatman described to me how they would heat the bamboo under a fire to bend the ends of the large akas. Synthetic line is used to lash the frame and the amas together. We saw a few bancas under construction on the beach and it appears that they use an epoxy compound to seal the joints in the hull. Many fishermen build their own bancas, using old diesel engines and scavenged parts. Despite strong breezes and good sailing conditions, we never saw any boats with sail rigs.

In Pangasinan the fishermen would haul their bancas onto shore when not in use. In El Nido they would leave them anchored in the water at night, in water so shallow you could wade out to them from the beach, When the tide went out they would be left high and dry.

We saw some fishermen pulling in a net that was cast just off shore, and one who had come from his banca. His catch looked pretty meager -- just a few small silvery fish. Despite all the fishing activity on the water and on the shore that day, we really didn’t see many fish, probably because this fishery is depleted.

A meager catch.

With 7,100 islands, the Philippines has the world's longest discontinuous coastline. Over a million Filipinos are engaged in marine fishing, the vast majority using traditional methods such as net fishing from small boats. Commercial fishing operations from Japan, Australia, Canada and the United States have a large presence in the waters around the Philippines. They use industrial fishing methods such as large-scale trawling and purse seiners that clean the open ocean of fish. This has resulted in fewer fish along the coastal areas where subsistence fishermen live. As the stocks of fish decline, coastal fishermen have to venture farther out to sea to find fish. This requires a greater investment in fuel and maintenance, to the point where they can’t afford to eat what they catch, but instead have to sell it to meet their expenses. The extra time they spend chasing the fish farther out to sea also means that they have less time to spend on supplemental farming at home.

One tragic outcome of the increasing scarcity affecting subsistence fishermen is that some have turned to dynamite fishing -- a more cost effective, although extremely destructive, method. The way it works is that a fisherman throws dynamite into the water, creating an underwater explosion which kills all the sea life in the immediate vicinity. Many dead fish sink to the bottom, but some of the dead and stunned fish float to the top where they are easily skimmed off the surface.This is a common method used to capture tropical reef fish for aquariums.

To make matters worse, even more people are migrating away from economically depressed inland areas and toward coastal areas, increasing the number of people dependent on fishing.

Fish for sale at Dagupan market.

National Geographic has brought attention to the problem of overfishing in a short presentation which I highly recommend watching called “Still Waters”. The case they present is that commercial fishing operations of the rich countries are basically taking fish out of the mouths of subsistence fishermen in poor countries.

A banca re-purposed for tourism, complete with lifejackets and Hello Kitty sun shade.

Some fishermen have turned to tourism to make a living. We saw a couple bancas for rent, inlcuding one that would sit on the beach in front of Happy Ripples waiting for business. For about $1 per person they would take you out on the banca for an hour. In addition to the boat’s skipper, a small group of vendors would show up at the beach in front of the resort, patiently waiting and hoping to sell their handicrafts.

GO-MED: The Baguio Mission Video

View on YouTube.

The way I usually make a video is that I shoot everything and hope that I can cut it together into some kind of story afterwards. There actually isn't a lot of planning involved. When interviewing people I might have scratched down four or five questions beforehand, and then sometimes I forget to bring my questions. And then there is quite a bit of time spent setting up the shot and getting people wired for the sound. So my subjects, Dr. Peter Blair, Betty Allan, and Danielle Delves, deserve a lot of thanks for their participation in this video. You accept a huge responsibility when someone entrusts you with their moving image. I can think of probably dozens of ways you can make someone look bad and far fewer ways to make them look good.

Katya did a lot of shooting during the day and when I was done with my case list we would look for someone and somewhere to interview. The operating room I worked in during the first week had amazing natural light. One wall was made up of frosted windows, so it was perfect to shoot in. We did our first interview with Dr. Blair there. Unfortunately, later on when we wanted to shoot in it the GYN team was operating in it. I really wanted to record all the interviews in the hospital because Baguio General is such an interesting facility, but it was difficult to find locations that were reasonably private. We also had serious issues with ambient noise, such as chatter and air conditioners.

The short clips are a small part of the interviews we recorded, and a lot of good material was left out. It is amazing what you can find out about someone in a formal interview, stuff that wouldn't come out in everyday conversation. I probably wouldn't have known how passionate Dr. Blair was about the problem of poverty (not only in the Philippines but in Canada as well) for instance, or the story Betty told about the kid with burns (that happened during a previous mission, by the way). One thing I learned is that people tell some of the best stories when the interview is over and camera has been turned off. Next time, I plan to keep the camera running after I've announced that we are done.

As far as the equipment we used, we had a Canon Vixia HF M31 camcorder, and a Canon Rebel T1i EOS 500D. The Rebel shoots HD at 1080p 20 fps, but focus is only manual in video mode. Katya also used her point and shoot Nikon which shoots in HD. We used a prime 50 mm 1.4f lens for the interviews, which works really well for shooting indoors with natural light, and a Zoom H1 portable digital voice recorder attached to a tiny lavalier mic for sound.

In Search of the Filipino Barrel Man

Katya exploring Baguio Market. View on YouTube.

I’m not much into souvenir shopping. I do enjoy browsing gift shops but I don’t bring home a lot of gifts. For one thing, I don’t like haggling or the feeling of being ripped off. For another, in the age of globalization, there is very little that is truly unique that you can’t buy off the internet if you really want it. And when you do find something interesting, you can’t be sure if it was made by a local artisan or mass produced in Fujian, China. In Mexico, for instance, shop vendors would tell me that that their “Maya Calendars” were hand carved by their brother, when it was obviously made out of resin poured into a mold, and looked exactly like a hundred other calendars everyone else was selling. I don't understand how they were able to make any money when everyone else was selling the same stuff, probably purchased from the same Chinese manufacturer.

My father works for Holland America as a cruise ship doctor, and my parents have spent a lot of time cruising around the world. My mother said that in the ports in the Caribbean the gift shops would be selling the same gifts and jewelry that were being sold in Alaska. It’s as if the cruise ship companies or their affiliates built these quaint little towns from the ground up, complete with a Pizza Hut and KFC, just so that the tourists would have a place to get off the boat and shop. None of the products for sale are actually locally made and there is no sign of any thriving indigenous culture.

What makes a good souvenir anyway? Do you look for something useful, creative, skillfully made, or entertaining? I imagine that people value uniqueness and a connection to the country they are visiting, and preferably something made by local artisans. It’s good to know that your purchase supports the local people and industry. For instance, I was a little disappointed when I bought a stuffed toy lizard in Maui for my daughter, only to find out later that it was made in Seattle. The degree of difficulty in the acquisition of an object is important too; it kind of deflates the excitement when you realize that the perfect gift item you found in a tiny store in the mountains of the Philippines is readily available at the Cost Plus World Market import store close to home. You can thank globalization for making souvenir shopping a little more challenging.

Katya and I expected that some of the best shopping would be at the Baguio City Market. A sprawling and labyrinthine area, it is hard to tell where the market begins and ends. Countless small shops are hidden off dark narrow pathways. With the exception of the meat section, the fish section, and the fruit and veggies section, they all seem to be selling the same things: canned goods, local peanut brittle, woven purses, native textiles, brooms, wooden carvings, penis ashtrays, and of course the filipino barrel man.

The filipino barrel man is one of the most famous souvenir items from the Philippines. It is small carved wooden figure of a man standing inside a barrel. If you pull the barrel up, his oversized penis springs out, fully erect! Like the giant wooden fork and spoon wall hangings, it is unquestionably filipino.

I’ve been searching the internet about the history of the barrel man, and unfortunately there is very little written about him. He originates in the Cordillera highlands around Baguio, but can be found all over the Philippines, even in high end gift shops in Manila around Ford Santiago, as well as the International Terminal of Ninoy Aquino International Airport. He is assumed to be an Igarot man. The carving is crude and lacks details, however, and you couldn't tell he is Igarot from his clothing -- he’s naked! It is only clear that the man has long hair and is wearing a head band.

The asking price for the barrel man in Baguio is about 100 pesos, which is a great deal, considering that at the gift shop in Intramuros in Manila it is selling for 360 pesos (but since everything in that shop was permanently half off, they were really asking 180 pesos). That is only for the smallest sized barrel man. They come in various sizes and the larger sizes go for more. I found a large barrel man for sale on eBay for as much as 74.99 USD (“Buy It Now”). Maybe this puts the value of the barrel man into the proper perspective. Or it only shows that the only people selling anything on eBay these days are opportunistic resellers.

Barrel men video by supergreen34 (not mine).

All of the modern barrel men look exactly the same, which suggests that they are all made in the same factory, or maybe in a few factories under the same management. But I was able to find a number of different iterations of the barrel man for sale searching for "vintage filipino barrel men" online. In one, the figure is more realistic and the features are more refined. Another one looked very old. The figure was highly stylized, and only abstractly resembled a human form. Unlike the modern version, the arms of the figure do not spring out, but are folded across the chest. The wood is dark, almost black, and there are white designs painted on the barrel. Could this be an early version, perhaps a prototype, one of the very first filipino barrel men?

Another interesting item we found was the cane toad purse. It is the body of a real toad that has been tanned and fashioned into a small purse, usually with a zipper across the chest and an added shoulder strap. It’s a unique accessory, complete with plastic googly eyes where the real ones used to be.The cane toad is not native to the Philippines but was brought there in 1930 to control pests in the sugarcane fields. It subsequently became the most ubiquitous amphibian in the islands. So these cane toad purses definitely could be made locally. I am suspicious though because identical cane toad purses are being made at The Toad Factory in Australia.

Other unique items are small purses made out of recycled juice containers (made by the Womens Multipurpose Coop in Baguio), the famous Baguio peanut brittle, and wooden hand-shaped chairs. By “hand-shaped” I don’t mean “shaped by hand”, but rather “shaped like a hand”. The hand-shaped chair design I suspect is not native, but instead was inspired by the surrealist Mexican artist Pedro Freideberg, who first started making hand-shaped chairs in 1962.

The other item I thought was uniquely filipino is the hand-carved highly polished wooden penis ashtray. When I was a kid decades ago, I saw them in Baguio at the gift shops around Mines View Park. There were tables covered with rows and rows of them, many more than you see these days and out front where passers-by could easily see them. It is something that you don’t easily forget. I had assumed that they were a sacred fertility symbol of the Igarot, the mountain people, central to their animist religion. I didn’t even know they were ashtrays!

Apparently you can buy wooden penis ashtrays in Bali that look exactly like the filipino ones. What surprises me is that the penis ashtray is a well-known Bali souvenir. So what is the provenance of the penis ashtray? Did it originate in Indonesia or the Philippines? The fact that I’m asking the question means that the value of the penis ashtray as a souvenir has been hopelessly degraded. It is no longer uniquely connected to a particular people or place. Years ago the penis ashtray meme must have made its way from one tourist destination to another, and a local artisan thought, “I can make this and these stupid foreigners will buy it!” Now it's just a funny ashtray mass-produced for tourists, devoid of any cultural significance. They might as well be selling them in gift shops in Mexico or the Caribbean.

Panagbenga

View on YouTube.

 

We were lucky to be in Baguio at the time of the start of the annual flower festival, known as Panagbenga. “Panagbenga” is a Kankanaey term that means "a season of blossoming, a time for flowering". The month-long festival was created as a way for the city to rise up from the devastation of the 1990 Luzon earthquake. It starts with a parade of elementary school kids that runs through Session Road downtown and ends in a street dancing competition at the Athletic Bowl. The children come from all over the region, riding in on jeepneys. The staging area happened to be on South Drive, right next to Ating Tahanan. We were advised that no taxis would be running in the morning, and to leave for work early that day because the street would be crowded. Everyone wanted some extra time to enjoy the spectacle in the staging area anyway. Katya and I decided to take the entire day off to see the opening parade and festivities in Burnham Park downtown.

To see my Panagbenga photo album on Facebook, click here.

Our Single-Use, Disposable Culture

Empty operating room at Baguio General Hospital

A favorite topic among medical people when discussing working in a third world country is “how bad things are over there”, referring to the the limitations on supplies and equipment as well as the weirdness of the pathology. I like to reply with, “It was really bad. They wash and reuse gloves!” Then I like to show them pictures of the rusty chairs and equipment that looks like it was left over from the 1960s. Those kind of stories make us in North America feel fortunate that we have the latest equipment and technology at our disposal. We can all be proud of the health care industrial complex that we have built! But those stories also highlight the ingenuity of people when challenged to work with the limited resources in developing countries.

Sterile surgical instrument set, covered with reusable cloth.

 

THE SINGLE-USE, DISPOSABLE CULTURE

One way to contrast the two medical systems is to focus on the use of disposables. If you are the type of person who cares enough about the environment to recycle, shop for groceries using canvas bags and avoid buying bottled water, you would think the amount of medical waste we generate in this country is obscene. Health care produces a massive amount of garbage, and operating rooms and labor and delivery suites together produce the largest fraction of it --  70% of a hospital’s waste. It is not all paper drapes and plastic containers, but also includes highly engineered, precision instruments. There are a number of reasons for this. There is a trend to make everything single-use and disposable. Prepackaged, single-use instruments guarantee sterility and quality. Also, hospital infection control committees have increased efforts to totally eliminate any risk of hospital-acquired infections, especially methicillin-resistant staphylococcus aureus (MRSA). They do this by making sure nothing that touches a patient gets reused, especially when used on patients who have had any history of MRSA. I also can’t help but wonder if the profit motive also influences the decision of medical equipment manufacturers to push single-use disposable devices as well. 

A list of the devices in anesthesia practice which used to be reusable and now are routinely individualized and disposable includes pulse oximeter probes, blood pressure cuffs, EKG cables, laryngeal mask airways (LMAs), patient gowns, towels, surgical table covers and linens, arms restraints, and Hovermatts (a inflatable mattress used to move extremely obese patients -- an increasingly important piece of equipment these days). Someone must have calculated that it costs more to wash, process, and resterilize all this stuff, especially if you are short-staffed. Many anesthesia technicians and nurses I have spoken with about this issue actually prefer disposable equipment because they don’t like having to clean used equipment, especially if it is something covered with blood or secretions. Even after my hospital contracted with a medical recycling company to clean and reprocess this stuff, the nurses would still throw them away rather than toss them into the recycle bin.

In my hospital, we are not allowed to use injectable drugs from one vial in more than one patient, even if the drug vial states that it is intended for “multiple use”. This is ostensibly to prevent cross-contamination from one patient to another, although this is easily avoided if you simply don’t use a dirty syringe to draw up your medications. The real reason has to do with accounting and billing: pharmacies can charge a patient for the cost of an entire vial, but can’t charge multiple patients for the cost of a fraction of the drug taken from one vial. We are supposed to dispose of any unused medications, which means that a lot of half-filled vials of expensive drugs get thrown away. The exception to this has been whatever drug of the week is currently in critically short supply, then we are allowed to save the unused portions of that particular drug.

Surgical instruments are also totally disposable now too. Manufacturers say having prepackaged, sterile equipment helps expedite the device preparation process. They argue that reusable instruments have hidden costs: instrument repair, the labor associated with cleaning and sterilization, and OR time lost because of instrument failure. With prepackaged, single-use instruments the cost of cleaning and sterlization is eliminated. Probably more importantly, like with drug vials, it is easier to track the cost of the instrument and pass that on to the patient.

There is a hidden cost to single-use instruments too and that is cost of disposal, not to mention the environmental impact, a cost that is passed onto the public. There are also human costs. Most single-use stainless steel surgical instruments are manufactured in factories in Pakistan and undergo final finishing and quality control in Germany before being shipped throughout North America and Europe. Since Pakistani factories only pay their workers $1 for a 12 hour day -- less than a living wage -- they rely heavily on child labor. 

In contrast to single-use instruments, high quality long-lasting German made steel surgical instruments intended for repeated use can be resterilized and reused about 3000 times. Although the initial cost and carbon footprint is greater, with repeated use the overall cost and environmental impact is much less compared to single-use instruments. But for reason this doesn't seem to make financial sense anymore. 

 

REDUCE, REUSE, RECYCLE

On our mission we had to make the most of our limited supplies and conserve our disposables as much as possible. I took inspiration from the resourcefulness of the locals. I didn't reuse my gloves, but I used the same anesthesia breathing circuit for a week, and just changed a disposable bacterial filter/humidifier at the patient end. The anesthesia mask, made for single use, was washed between cases, along with the disposable oral airway and non-disposable laryngoscope blade. I had a more than dequate supply of endotracheal tubes. These were donated because they were past their expiration date or the packages had already been opened; it is common practice to open sterile equipment before an operation to save a few seconds, and not use it.

To conserve needles and syringes I mix drugs in the same syringe and deliver them concurrently, such as ondansetron and dexamethasone. Before doing this it is important to consult a compatibility chart to see whether they are truly compatible. Lack of visible precipitation alone is not evidence of compatibility.

We used facemasks folded over and tied around the patients arms as arm restraints, and used the same pair all week. In the United States our containers for hazardous sharps waste are single-use and specifically manufactured for that purpose, with a lot of safety features (colored red, with a lid that automatically prevents overfilling and locks down for final disposal). Instead we improvised with empty plastic IV bottles with a hole cut on the top.

Improvised sharps container

THE PROBLEM OF HYPOTHERMIA

One problem that we could have dealt with better is intraoperative hypothermia. You would think this might not be a problem in a tropical climate, but since Baguio is over 5000 feet above sea level the weather is usually cool and we also kept the operating rooms is air-conditioned. A patient's drop in core temperature in the first hour of surgery is primarily due vasodilation produced by the induction of anesthesia. Vasodilation redistributes heat from the core to the periphery, and the only way to prevent a drop in core temperature is to actively warm the patient for about an hour before surgery. Additional heat loss during surgery is caused by conductive heat loss by contact with the OR table, radiative loss from exposed skin, irrigation with room temperature solutions (into an open abdominal cavity for instance), infusion of room temperature IV fluids, and ventilation with cold, dry gases. On arrival to the recovery room, we had patients as cold as 33.2 degrees C. Hypothermia is not only uncomfortable for patients; it also slows emergence from anesthesia, increases oxygen consumption by inducing shivering, inhibits coagulation, suppresses the immune system, and increases the risk of postoperative wound infection. If severe enough, it can cause life-threatening cardiac arrhythmias.

Unfortunately, we lacked any practical, effective means to prevent intraoperative hypothermia. The best way is to use a forced air warming system, which works by blowing hot air into a single-use, disposable inflatable blanket. Imagine turning a big hair dryer on "high" and blowing it underneath a blanket -- toasty! Even regular blankets were hard to come by. After some discussion with the recovery room nurses, the surgeons agreed to turn the air conditioner off in the OR. They suffered under the hot gowns and had to have nurses wipe their brows, but the patients came out a little warmer.

The BGH recovery room nurses use an improvised radiant warming device, which is a single lightbulb surrounded by a thin plywood shade hung over the patient. They let our team use them when there was enough to go around. I think the yellow light gave more of an impression of warmth than actual heat. It only used a 60 watt bulb.

The Canadian recovery room nurses put on knit wool hats (“toques”) on patients, and also came up with the idea of putting blankets and hats on our patients preoperatively to keep them from getting cold while waiting for surgery. For the next mission they are planning to bring a bigger supply of toques and socks to give to patients.

 

THE MONSTER

Remember the patient who had the the large dermoid cyst removed? I caught up with rounds on the gynecology ward just as they were seeing her on the first postoperative day. She looked very happy. She wanted to see pictures of the mass, which she referred to as her “monster”, so Katya ended up printing out pictures for her to take home with her. Our anesthesia coordinator Dr. Hoskin told me that all three of my patients from the day before were comfortable overnight. Despite only receiving Tylenol and ibuprofen the night before, the only thing that they complained about was discomfort from the urinary catheters, so the paravertebral nerve blocks we performed must have worked well. 

[Photographs copyright Katya Palladina]

Vegan Adventures in Baguio

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Traveling overseas on a plant-based diet requires a little planning and resourcefulness. It’s good to request a special vegan meal for your international flight, for instance. For that you need to call the airline in advance, at least 24 hours before, or maybe it’s within 24 hours. I don’t remember exactly because honestly I don’t do it anymore. But when I do remember to do it I am usually pleased with the results. You get your food before everyone else and it is a much less greasy and more interesting choice than the usual "chicken or beef" smothered with cheese product that everyone else gets. The airlines purposefully make it difficult to find the telephone number to call to make your request, so these days I just deal with what everyone else gets but only eat the veggies. I will also carry-on my own food such as nuts, dried fruit, and LARA bars (which are basically nuts and dried fruit). Most of the time I just sleep as much as I can on the plane and skip the meals. Flying in economy is so miserable anyway that you don’t really want to be conscious for it. Essential gear: inflatable neck pillow, a beanie (toque if you are Canadian) to keep your head warm and pull over your eyes, and Ambien.

While we are on the subject of eating and flying, I should mention one weird trick discovered by a mom to compleletly cure jet lag in one day. Fast for 16-12 hours prior to the time when you want to wake up. You can drink liquids but nothing with any calories in it. Then have a big breakfast. The caloric intake overrides the control of the suprachiasmatic nucleus over your body’s diurnal rhythm and resets your biological clock. I will also use sublingual melatonin to go to sleep at night, about 1 to 3 mg. Using this technique we didn’t have any problems with jet lag at all.

 Katya at Narita International Airport

When traveling I do allow myself some flexibility in eating. When in Peru, for instance, I couldn’t resist that chance to try cuy (guinea pig), or eat the sushi in Japan. That might offend some people who say that I’m cheating, being hypocritical or “unpure” or something along those lines. Whether I am or not depends on the reasons I decided to stay on a plant-based diet in the first place. For me it is primarily for health reasons, because there is a lot of scientific evidence that a whole-foods, plant-based diet can prevent and even reverse the progression of the most common chronic diseases. I am also concerned about animal welfare, and especially the effect of factory farming on the environment. Lastly, I am a little concerned about my carbon footprint. Not eating meat is the single most effective thing you can do to decrease your carbon footprint, even more effective than switching from a standard car to driving a Toyota Prius.

In developing nations, you take a risk of getting gastroenteritis from drinking tap water, or eating raw fruits and vegetables and street food. Filtered water was available everywhere in large jugs. I also brought my own Lifesaver bottle, which I could use to filter tapwater. It came in very handy when bottled water was scarce and you just wanted some to brush your teeth. (Yes, you should avoid brushing your teeth with tapwater.)  The Lifesaver filters down to 15 nm and produces sterile water. It filters out all microorganisms, including viruses.

The higher end restaurants might have washed their produce in filtered water. You could wash your own vegetables in filtered water, but that alone might not remove the biofilm. Sprouts and root vegetables for instance, are known to actually absorb surrounding soil microorganisms into their tissues, developing a commensal relationship with them. That’s one of the reasons eating spouts is risky, even in the United States. What if that lettuce was fertilized with raw human sewage? You could try adding a little bit of bleach to it but I don't know how effective that is. I would have to be really craving a raw salad to go before I go to that much effort. In general I just avoided eating any raw vegetables or fruits unless I peeled them myself.

We were prepared to cook a lot so one of our first stops was the grocery at SM Mall. The kitchen at Ating Tahanan was equipped with pots and a wok, knives, and cutting boards, but we needed to buy cooking oil, soy sauce, spices and plastic wrap. We cooked mostly veggie stir fries and rice, tofu adobo, and that green mango/papaya salad I mentioned earlier.

Raw green mango/papaya salad.

The meals they served in the hospital were excellent. They provided us with breakfast and lunch, so there was always a buffet set out in the lounge, which was perfect for grazing between cases. We would get a lot of rice, grilled eggplant, okra, chayote and sayote greens, green beans, bananas, watermelon, mangoes, papaya, and strawberries, a specialty of the Baguio region.

I was surprised at the vegetarian options as far as restaurants went. There is a place called Bodhi at the food court at the bottom level of SM Mall which served vegan versions of filipino dishes, a lot with some very convincing fake meat. There is another vegetarian restaurant on Session Road called Oh-My-Gulay! It is a little hard to find because the signs aren’t very good, and it is on the roof of a 5 story building and as far as I could tell only accessible by the stairs. The restaurant has two levels and a balcony, on one side looking across town to Burnham Park, and into a garden courtyard area with a fish pond on the other. The interior is really very interesting and worth the visit. The food was good, but the waitstaff seemed less than enthusiastic about working the day we were there, even though the restaurant was nearly empty. Also the bathrooms were a little sketchy and didn’t have any toilet paper.

Don’t even bother going to Jollibee or Chow King; there is nothing at all to eat there, except maybe the fries at Jollibee if you are desperate. We shared a Super Halo-Halo at Chow King, because Katya wanted to try halo-halo and ube ice cream.

One of the Canadian nurses who knew we are vegan said that he saw some vegan sausages at the public market, which really surprised me, because we had been there, and didn’t see any. He showed me the picture he took on his iPhone. The sign actually said “Vigan” sausages, which in this case refers to a type of sausage made from garlic and pork that comes from the capital of the province of Ilocos Sur called Vigan. I think he really thought that they really were “vegan”, but i suspect the concept has yet to reach the filipino consciousness.

In the video Katya describes how to eat like a Filipino with a fork and spoon. The kitchens of filipino homes are often decorated with a giant wooden fork and spoon. Filipinos eat with a spoon in their right hand and a fork in their left, and push the food onto their spoon with their fork. They don’t use knives but use the edge of the spoon to cut food. This is possible because the meat is usually prepared in small pieces instead of big slabs, and also cooked very well-done. The cooking style probably evolved to avoid rare meat because bacterial contamination was common in the warm climate.

In 2006 in Quebec, a Filipino-Canadian boy attending Grade 2 at Lalande School in Montreal's Roxboro district was repeatedly reprimanded by a lunch monitor for eating with a fork and spoon at the same time:

The boy's mother met with her son's lunch monitor, Martine Bertrand, after she told him that his habit of eating his noodles with both a fork and a spoon was disgusting.

Maria Gallardo said she explained that the practice was a tradition in the Filipino community, but that Bertrand was unwilling to compromise.

When Gallardo tried to meet with the school's principal to address the situation, Normand Bergeron dismissed the request and said her son should learn to eat like other Canadians.

Ultimately, Quebec's Human Rights Tribunal ordered a Montreal-area school board and two of its employees to pay a total of $17,000 in damages to the family of the boy for their cultural insensitivity.

SM Mall, Baguio

When Katya and I needed to do some groceries we would walk or take a taxi to the SM mall. SM started out in 1958 as a department store in Manila that specialized in shoes, called “Shoe Mart”. In the 1970s they changed the name to “SM” and gradually expanded in the decades since. Now SM is one of the largest shopping mall chains in the world. The company went public in 1994 and grew to become the largest company listed on the Philippine Stock Exchange in terms of revenue. SM owns 46 shopping malls all over the Philippines and even branches in China. The Baguio SM Mall was opened in 2003, to the dismay of some prominent community leaders who lamented how it put some a lot of mom-and-pop stores out of business.

The mall is a popular place to hang out. Within its bright, clean and air-conditioned interior you find the modern equivalent of the food stands you see on the street, selling chicharon (deep fried pork rinds), babingka (spongy rice cake), buko juice (young coconut water), and green mango with bagaoong (shrimp paste).

Another interesting finding was a counter called “Vape King”, right across from and indoor carosel and an electronics store selling large flat screen HDTVs. Vape King sells mini portable vaporizers for “herbs”. This obviously meant marijuana but they also sold packages of flavored tobacco to make it look legitimate. Vaporization is the process of heating dried cannibis leaves to a temperature just below combustion. It releases the resin in vapor form while avoiding the production of irritating, toxic and potentially carcinogenic combustion products. It does not produce smoke and minimizes any odors, and reportedly enhances the flavor of the weed.

Unlike my home state of Washington, marijuana is still illegal in the Philippines. In fact, they have some of the toughest marijuana laws in the world. The first time you get caught smoking you can be sent to rehab for six months. After the second time, you can be sent to jail for 6-12 years. If you get caught growing it, you face life imprisonment or the death penalty.

Despite that, the Philippines is second only to Mexico as the world’s largest producer of marijuana. The plant is not native; the seeds were first brought to the Philippines by American servicemen staying at Camp John Hay in Baguio and Sagada during the Vietnam war. They asked local farmers to plant it. Seventy percent of the country’s marijuana now is grown in the the Cordillera Highlands around Baguio. It’s not a hard decision for poor native farmers to switch from growing other crops to marijuana, since it obviously pays much better than vegetables. The plantations are hidden in the mountains in areas inaccessible by any vehicle, which make them difficult to find and eliminate. They are controlled by organized crime -- the narco-mafia -- and guarded by kids with AK-47s. The weed is carried out on foot trials and sold somewhere to the Japanese Yakuza, Chinese triads, and West African gangs, then smuggled into Japan, Canada, New Zealand, and Europe.

The Philippine Drug Enforcement Agency and Philippine National Police are fighting a fiece war on pot, constantly finding plantations and destroying plants. Earlier this month, they claimed to have destroyed 260,500 fully grown marijuana plants in an operation in Kibungan and Bakun towns north of Baguio. Curiously, no cultivator was arrested in the operation. Athough this seems to suggest that the PDEA is winning the war on pot, back in 2009 the PDEA had already declared victory in the Benguet province, declaring it "marijuana free". They accomplished this using programs that assisted farmers to switch to cultivating bees, silkworms, anthuriums, and the root crop yacon.

When people are vaporizing pot instead of smoking it in joints or out of a pipes made out of empty beer cans, that indicates to me they are moving up in the world. Indeed, the people that smoke it in Baguio are primarily professionals and college students. Students from the provinces where marijuana is grown are also often the ones transporting in to the city and selling it to help pay for their education.

The other favorite drug of abuse is “Shabu” or methamphetamine. I had suspected that this was a problem because during my first few days in Baguio I was suffering from a cold and went asking for pseudophedrine at three different pharmacies, but couldn’t find any. I think they have made it totally unavailable because of its use as a precursor in the manufacture of meth.

 

The SM grocery store at the mall has a large produce department with an amazing array of tropical fruits and vegetables, and about a dozen different varieties of rice. Along with eggplant, bitter melon, long string beans, carrots, and mushrooms, Katya and I picked up some santol, papaya, mangosteen, a small variety of banana, and of course, mangoes. There were others fruits that we didn't know the names of or how to eat but we bought them anyway just to try them.

The mangoes were incredibly sweet and ripe. The Canadians planned to bring home boxes of them. Unfortunately you aren't allowed to bring any into the United States. We also picked up some green mangoes for a green mango/papaya salad. Their “green” mangoes are similar what stores sell in the states as “ripe”.

Another useful thing to know is that you can change money at the SM customer service counter in the grocery.

A taxi line is conveniently located right outside the mall by the grocery store. People roll their carts right up to the taxi and an attendant helps you with your bags.