When I first got to Thailand and was wandering around, checking out Bangkok, I was amused to see signs on the hotel doorways declaring, "NO DURIENS". I knew about duriens because there is a traveling ultimate team based in Jakarta called Durien. At first I figured it was a place like somewhere in Connecticut; or perhaps a company, as Jakarta is one of the few Ultimate teams that gets corporate sponsoring (though sponsorship is becoming more common, raising moral issues for this sport with its roots in disorganization). The Duriens explained to me that a durien is a fruit that smells so foul, it is illegal to transport aboard airplanes. One whiff will fester in your nostril for days and ruin the meals between. I was amazed I'd never run into this fruit in Asia before, though perhaps thankful.

I had taken a photo of a sign reading "Ancient Ice Cream" in a market in Chiang Mai on my first escape from Mae Sot, and had been disappointed when I got home a reviewed the pictures and seen that one of the choices had been durien flavor. I'd heard that the smell of the durien is awful, but the taste is sweet and quite nice. I also wondered if taro flavor would have been nice too, or just glued the teeth together, since taro is what poi is made of, which is what Hawaiians use for building wood furniture.

I had a chance to try durien ice cream in Mandalay. In its frozen, milky form it has a sweet, tooty-fruity flavor, but then a bitter, stinky aftertaste like a cross between vomit and ammonia. At the clinic and Myanmar I'd had the opportunity to eat, and finish with relish, many dishes I would never consider ordering again. The concept of "liking" food had almost left my vernacular. Almost everything I put in my mouth would elicit a "hmm, interesting," and if it didn't taste dangerous or consist of pure animal flesh, I would most often finish it. While in Thai culture, I understood that it is considered eminently good manners to leave a few bites of food on the plate to demonstrate that you had eaten so much of your meal only because it was tasty and not because you were so hungry that you finished it all and are perhaps still hungry. I wasn't sure if it was the same in Myanmar, but it became almost a compulsion for me to finish any dish put in front of me. Because there was almost nothing I could say I ate with relish, if I didn't pledge beforehand in a vague, semi-binding way to finish my meals, there would be a chance I'd quit before the third bite. So down it all went.

My first failure was the durien ice cream in Mandalay. I got about halfway through and couldn't stand it anymore. Despite the beggar woman with the child on her back that I was refusing to acknowledge, I ordered a helping of strawberry ice cream to wash down the grave insult to my digestive system, and I was still belching ammonia durien fumes in the morning.

There is only one begger that I have seen in Mae Sot, and it is the healthy little boy who seems to have grown three inches since I got here, whom I treated to lunch on Valentine's Day; sometimes he has his friend in tow, but he's the leader when they're a pair. He comes and begs at the restaurants where Westerners eat, and often stands looking at me. I haven't given him anything since, and I have steadfastly refused to give to anyone while I'm eating. For starters, I think it's rude and aggressive and I don't like to be bothered when I'm eating, especially if I'm reading. But second, in bigger places like Mandalay you're a sitting duck while you're eating, and once you give to one woman with a baby on her back, you have to give to twenty because they're all around. I do give to women with children, as I have heard that most money to men goes to booze & drugs, but most money to women goes to feed the family. I also won't give to women with children late at night, as the little ones should be home sleeping. I suppose late is when Westerners are drunk and jolly and generous (if they're the type), but one needs to justify oneself somehow and one way is by making up little rules (but never saying never).

Back in Mae Sot, coming home the opposite direction from what I usually take past the jail, I noticed two things. First, before the Indiana Jones wooden footbridge, the yard that had been full of burned-up, rusted out pick-up trucks and cars (reminiscent of a yard in rural America) had been cleaned up. Second, there was a big dump truck parked in the yard of the neighbors next door to my house. It was one of those big ones you see at home hauling gravel for road construction. This one was full of… duriens.

As I entered the guest house yard I overheard another guest asking the husband of Kritsana, the lady who runs the g.h., if they could settle up her bill. His English is much shakier than Kritsana's, so the husband said, "Oh, oh, yes, my wife, uh…" as I passed by. I'd just seen Kritsana going into the neighbor's yard and said, "I think she's at the duriens," and he went scurrying off in the right direction. I guess would be hard for everyone not to know about a dump truck full of duriens living next door.

When I saw Kritsana later I commented that now I knew where she was getting her duriens. I had been smelling them as I passed the owner's house for the past week, but she said they had just come today. This family does seem to eat a lot of them. She invited me over to sit on the landing in teak steps leading up to her house, and offered me a fruit I'd never seen before. I was delighted as I am sometimes a little scared of new fruits around here. Never mind all the dire warnings about eating raw things and then only peeling it yourself while you stand on one foot and hum show tunes – there are duriens around here! There is something at the market this season that looks like a pretty durn close relative to a sea anemone: deep purple, with green and red tentacles. I've been stung by anemone, and the market ladies probably drink the tap water, so I haven't touched 'em yet.

Kritsana's 15 year old son was cruising around the driveway on his mountain bike, going along the path to the guest houses then back past where we were sitting, through his mother's garden and over the small mimosa plants, and finally coasted right into the lattice from which a few orchid plants were hanging. She clicked her tongue at him.

The fruit Kritsana offered me was a deep purple like the one in the market, but with a smooth skin, and about the size of a racquetball. It had a four-leafed green little cap. She squeezed it open, splitting the sides, revealing a hot pink inner padding of the peel were the white inside an orange rind would be, and six white morsels of fruit inside, organized like pieces of an orange. They are too tender to be pulled out with the fingers, so the eater must suck them out one by one. Kritsana's husband had come out of the house and looked over her shoulder and said, "Ahh, that's a good one." There were five small segments and one big one. The big one had a seed that was not to be consumed, while the small ones were seedless. The flavor was gently tangy and very sweet, lasting, but with an after-sensation rather than an aftertaste. The texture was very delicate and slippery, but dense with flavor; kind of the opposite of a watermelon.

The flavor and the presence of the pit reminded me of an orange colored fruit I once had in Italy that had some kind of slippery seed or pit that I was told to play around with in my mouth for a while after eating the edible part, just cause it felt good. I've found the seeds of the tamarind to be a little like that too, but smaller and more prone to slipping down the throat. At least, this one was a little bit like that, but I didn't want to gnaw off the the entire membrane off the seed in front of Kritsana. Eventually, in private, I would and would find that the seed is actually a bit hairy and not at all very pleasant to play around with in the mouth. I was advised to choose the smaller fruits at the market, as the segments are less likely to have seeds.

Kritsana told me that this mysterious fruit was called a mangosteen, and then she started laughing. She said that the name is a joke about foreigners (she doesn't call us farangs, and I have never seen anyone in her family spit). The real name of the fruit is mangook, with the "k" somewhat swallowed. Foreigners have trouble hearing the difference between mangook and mango. Indeed, when she first asked me if I'd tried it, I'd looked at the purple fruit through the opaque plastic bag and said, "What, those are mangos?" So she'd taken to calling them "mangosteen" for my benefit as she explained how to eat it.

The story is that a shopkeeper is trying to explain that it is a mangook to a foreigner, who just isn't getting it because it just doesn't look like a mango. The shopkeeper gets so frustrated, he stamps his foot angrily and cries, "Mangosteen!" Kritsana is laughing hysterically at this point, and so am I, though it feels a big like my dad's "No soap, radio" joke. I asked her, "What does steen mean?" It means foot, as in the angry foot stamping on the ground. I gather that the foreigner's name for the fruit is thus something on the order of "Mango-damn it!"

It suddenly dawned on me that I could actually buy some of the weird fruits at the market and bring them home to share with Kritsana, who could show me how to eat them. If I had picked up the mangooksteens and tried eating them myself, I would have discarded the slimy white things inside and tried to eat the bright red lining of the peel, which I could tell was quite bitter just from incidental contact while sucking out the sweet insides. Kritsana laughed when I suggested I might like her help in eating some of the fruit from the market. She said the sea anemone fruit was just like the mangook, you just had to slice it open with a knife. She might understand if I put it this way: "I'm a little bit scared of the durien. Perhaps you can show me how to prepare so that I am not afraid to eat it?" I had a date the next morning at 8am, for breakfast with a durien. What a way to start a Saturday.
- posted by melle @ 5:13 AM

 
Just before I left for Chiang Mai last weekend, I had drinks with Dan and Jane and Yvonne, in honor of the latter's next-day departing to return to Australia to pursue a PhD, I think in public health. She plans to take the next 12 months to do it, then return to Mae Sot. Bravo to her, mother of three (youngest age of 18), running off to work in Thailand, then going for a doctorate at age 52.

There was a new face at that table - Jo, an Australian MD who'd just arrived. She's in the same boat as I, volunteering under the auspices of no organization. She plans to stay 6 months to a year - only she's more likely to stick it out as she's done this before in India. Lucky dog. She did Royal Flying Doctors in Australia. (don't ask me, I haven't found out much about it yet except that it wasn't always flying about to this call or that; she would be called to a remote location and flown in for a week or two or so and see lots of patients then go somewhere else or back to base.)

This week we've had a whole lot of births. Some I've come in at the very last moment and gotten to pull the baby's shoulders out in the right direction (how hard can it be to remember to pull DOWN to free the top shoulder, then immediately UP to free the bottom one so it doesn't split open the perineum??), but others have taken more work. The medics told me one gal was 7cms. but hadn't been checked in an hour, so when I did I found that the cervix was completely gone (good) on one side of the fetal head, but enormously swollen on the other (bad). such a cervix is loath to reduce (dilate, pull back behind the fetal head) on its own since it's so fat, and trapped between the head and the pelvic structures. The ideal thing would be to lie the mother on the opposite side to take pressure off the cervix, but in this case the fetal head was so low it was pressing on the mother's rectum, giving her the uncontrollable urge to keep pushing. So pulling teeth, I got the medics to teach the mother how to pant (to reduce the force of the contractions) while I tried to work the swollen half of the cervix behind the head. Poor girl, I had to keep my fingers in for three or four contractions to make sure the cervix stayed back. It worked fine and it was a lovely birth in the end.

It's amazing how I see every delivery mistake at least once. A common one I have seen a lot is as the baby's upper shoulder appears under the pubic bone, the medics try to fish out the arm by hooking the baby under the armpit. This is a HUGE no-no, as it can rupture some nerves or ligaments and give the baby a limp arm. Besides, such a move is totally unnecessary. Once the shoulder appears, you pull the kid the other way (up) and free the lower shoulder, then you're home free.

I have decided that the only way I'm going to get them to do births correctly is to be there with my gloves on for every birth I can, and that they'll see what I'm doing and I can give gentle nudges and corrections. Half the time when they see me with my gloves on, they take theirs off and walk away. I have taken to asking which of the spectating bunch will be doing the birth, then pull her aside for a little tutorial. There is a rubber baby doll that has had a black beard and red devil horns inked on, which I use for demonstrations on when to pull up or pinch or press down or turn. This way, the medic knows (as far as she understands, or can remember) what I expect. In the actual birth, we are both there with hands on, and I have found the four-handed method to be remarkably good, one I will have to keep in mind for the future. Most birth attendants be they MDs or midwives do births single-handedly (that is, with their own two hands), and until I got involved here I did two. But with trying to teach these guys to coordinate the different times to pull the baby up or down, while alternately trying to protect the perineum or the urethra of the mother, it's been great having someone else focus on directing the baby up or down while I play defense for mom. I haven't had to do a single repair all week.

I got to the clinic at the same time as Jo on Tuesday and she asked if she could come see what my living arrangements were at my guest house in the afternoon, as she's having similar troubles to mine when I first got here. Same-same but different in the other direction - she's paying too much for too nice housing and not enough mosquitos in the bathroom. It was raining like the devil at the appointed meeting time, so I wasn't surprised that I had an uninterrupted afternoon to read about spies in Egypt. There have been a few sprinkles from 5:30 to 5:45pm, but nothing like this monsoon typhoon for three or four hours that left branches strewn about the neighborhood. Jo did catch up with me as I was headed to the reservoir the following day, and we had a nice bike ride together before I took off to go running. She had brought her nice mountain bike from Australia, but didn't bring any shorts, fancying she was headed to a prim part of the world where bare knees were unacceptable. I told her to come back to the parking lot of the police station next door to my house at 6pm, to see the ladies in spandex hot pants and sports bras doing aerobics to the house music version of the hokey pokey. I pointed her to a sports accessory shop in town. She worried she wouldn't be able to find any in her size, but from all the chubby Thais I've seen scooting around on their motorbikes, I didn't think she'd have any trouble. She's of normal girth, and a normal build like me with a height that puts her at slightly taller than average and towering over the average Thai, that shorts wouldn't be required to cover in any case. We've made plans to run on Sunday, which is nice in principle except that I've never really liked having a running partner. At least on the Hash, I could pick people up and drop them at will, and do most of the run solo. With just one other person you have to adjust your pace, never mind keep the date in the first place even if you ultimately don't feel like going running. I suppose I can give it a trial run just this once and see how it goes.

Today at the clinic we had four births in five hours. The first two took less than an hour each. The third I stepped in to for literally 30 seconds, to help them pick up the lower fetal shoulder up and over the perineum (come on, it's not that hard!), then went back to the birth I was working on. I only stepped in that minute as I'd just put on new gloves and decided to take a look to see who was behind the curtain (though I'm sure the medic in charge would have preferred I pay no attention).

The birth I'd been involved with had been of a 21 year old first time mother, with a Chinese-looking face and long, tragic eyelashes. She was there with the baby's father, and she was working really, really hard. Once a laboring mum is "fully dilated", she's reached what we call "second stage", and the time limit is accepted to be two hours, though in NY we generally scream them out in under 45 minutes ("Come on, hold your breath and PUSH, 1-2-3-4..."). There's really no rush so long as the fetal heart is going at a good rate (110-160 beats per minute), and both the fetal head and body need time to rotate and descend a lot. I've been teaching the medics that it's important to listen to fetal heart sounds every 15 minutes in 2nd stage, and recognize that if they're good, that waiting is preferable to doing an episiotomy. Sophia hasn't done a birth in the past month while I've been there, and now that I'm there with my gloves on and showing no mercy in the technique department, so there's been no resistance. I think they're pretty amazed that you can do a birth without an episiotomy or lots of nasty tearing.

So I let this one gal take a rest for the first hour of second stage, figuring most often the fetus descends fairly well on its own. We did a little more directive pushing starting in the second hour, without much effect. The new-ish medic who was to do the birth had long ago taken off her gloves, and now Poe was there with me, doing an impressive job of motivating the mother to push. With the clock ticking on toward two hours, I felt around the fetal head and was surprised that the mother seemed to have a lot of pelvic room but that the head was so stuck behind the pubic bone. Through the mother's belly it felt like the fetus' back was against the mother's back, which can cause a longer labor but shouldn't hold up a birth indefinitely.

I had the mother flip over so that her head was down and bum in the air, and tried to push the fetal head off the pubic bone, and rotate it into a better position. One possibility was that the cord was wrapped around the fetus and holding it back - a theory that seems unlikely when you think about, but we birth attendants agree from experience that tangled cords do seem to be present in many slow births. However, it was seeming more and more likely that the head had entered the pelvis in an awkward position and was just stuck. With the mother's belly hanging down, perhaps the shift in the weight of the fetus would give us room to maneuver. I pushed and prodded but the kid wouldn't budge.

Two hours and twenty minutes into 2nd stage, the fetal heart rate was up in the 170s with no decelerations, which is slightly faster than desirable but without a bad pattern. I wasn't terribly concerned, but I didn't think this birth was going anywhere. Dan and Jane are away in the islands this week, so I sent for Jo. I had seen Dan use the vacuum extractor once, but none of us present knew confidently how to work it. Jo look aghast at the 1950s oil rig-type contraption. With the fetal heart rate in the 180s now - a sign of stress - I for one felt the risks of trying the vacuum were less than those of an eight-hour second stage and the dead baby that might follow, and Jo agreed. It took three of us (me, Jo and Poe) about 15 minutes to put all the pieces together and figure out which pedals put on the suction and which let it off. Jo's plan was to apply the suction cap at a certain pressure until caput formed then increase the pressure, then either just rotate the head and see if the mother could do the rest, or just pull the baby out. I knew she was going for the second plan when she asked for lidocaine - local anesthetic, the humane practitioners precursor to an episiotomy. Unable to keep my mouth shut I warned, "You know, lidocaine causes swelling." Jo, the MD, gave me a kinder look than I deserved and said, "I know."

After a few minutes of fitting the suction cap on the fetal head and working the pressure pedals Jo turned to me and said, "I hope you're not terribly upset, but I think I need to give her an episiotomy."
"Oh, yes, I understand."
"I'd like to ask you to do it for me."
"Oh. Er. Alright."
I picked up the bandage scissors that have one flat, rounded end to protect the fetal head from getting poked, and made one determined cut at the perineum - and barely made a dent. They were as dull as a daytime soap. I tried the small, pointy ones, which were just as bad. It took me about four cuts, and I'm not sure I gave Jo much more room to maneuver, but she didn't ask me to cut anymore. The baby's head corkscrewed around as it came out, and the body easily followed. The heart rate was at 60 as Jo pumped air into the lungs with the ambu bag. Within a minute it was up to a comfortable 160. The little boy was crying and pink within minutes, weighed in at 2.88kg (6.3 lbs), and seemed to have a black eye. As usual, we laughed about his banana head, so moulded and stretched from the process. It looks horrible to parents who think their baby has two brains and it makes mothers cry, but a head that's been squeezed out of shape from a slow birth goes into a normal shape within a few days. Newborns are like rubber bands; this one's head had been turned around inside 135 degrees – just you try turning around and inspecting your own shoulder blades without a mirror! Yet his hands gripped strong and after a few minutes he looked like any newborn or banana.

I stood holding oxygen to the baby's face for the next hour and making sure he stayed conscious, advising the medics (again) that the baby should never sleep in the first hour. Many babies stop crying and spend the first hour looking around the world, checking things out, until they're put on the breast. This one had some menacing, pissed-off expressions that went well with the black eye. We got him to the breast as soon as Jo was finished stitching up the wretched epis. I would have to find a vitrier to sharpen those scissors.

That night, Jo found me at dinner where I was absorbed in Steinbeck's Of Mice and Men, which Jane had lent me. The curry on rice at this one place is safe to eat without looking (no dangerous little chilies plotting an ambush). She had a lime juice with me as she apologized for having me cut the episiotomy. I laughed that she has sought me out just for that, because I'm really not squeamish at all and hadn't minded doing it as it had been a necessary one. In fact, I was grateful for knowing definitively that the tools at hand were entirely unsuitable, and that elective episiotomies should be punished with tar and feathering. I had Saturday night plans for dinner with a Swedish couple and another friend of theirs, and invited Jo along. I thought it was so sweet that she came to find me to be sure I wasn't traumatized, and wasn't at all sappy about it. It's been nice to meet her, seeing there are other people out there in the world doing all the things I like to do, and with a similar temperament to mine. It's a pity she's female.
- posted by melle @ 5:09 AM