The Fat Ballerina: an anatomical review

Ballet Rehearsal, 1873 (Degas)

Fogg Art Museum, Cambridge, MA

I don't know what I was thinking, but last night I went to my first ballet class in, oh, twenty years. I knew it was going to be bad, painful, humiliating, etc. - but I didn't realize HOW painful! I've taken my muscles for granted. My gosh, ballet is HAAAARRRRRRD! And I never thought of it before as a full-body work-out - it was just dance, something I loved to do - but it's also cardio (when the teacher said we were going to repeat the tendu exercise I thought I was gonna pass out - just over tendus!), stretch, toning from head to foot. I can't believe I used to be able to hold these positions and do these steps the way I used to. I used to be good at this? HOW?! My muscles, core and periphery, are so weak now. It's humbling.

And this was just an "ELEMENTARY" ballet class. Thank goodness I didn't go to the intermediate class. I feel wistful thinking I used to be like those women who were taking the intermediate class en pointe (we were able to watch them in their gorgeous studio, renovated from an old church, with cathedral ceiling and huge stained-glass windows still in the far wall). I used to go to New York regularly and take classes alongside professionals from ABT and NYCB with the amazing teacher Willie Burmann, and do his high-speed, advanced class en pointe. Those days are LOOOOOOOONG gone! I got vertigo just doing turns across the floor -that NEVER happened to me before.

This morning my abductor hallucis wants pain meds and my "turnout muscles," which were never very good to begin with, are now wondering why the heck they were roused from a decades-long sleep. Now that I am older and more schooled, I had to look up these muscles in my Netter Atlas - the prized book in med school, with its beautiful anatomic illustrations, that made me feel that I had indeed entered the world of medicine at last. (I had to use Gray's here for copyright reasons, though).

Piriformis

Obturator internus and externus (internus shown here)

Quadratus femoris

and

the Gemelli brothers, Gemellus superior and inferior (I've shown "inferior" here because I feel sorry for his name).

To think that in medicine there's both a piriformis syndrome and an obturator syndrome! As we left the class one of the adult students, an older guy, said, "Well, I'm in pain from head to toe. So it must have been good for me." I guess so! It was enough to send this Fat Ballerina home with fantasies of having a glass of Fat Bastard with dinner... :)

Reminder: surgeXperiences Blog Carnival is Almost Here

As I round up the submissions for the upcoming surgeXperiences blog carnival, scheduled for this Sunday, February 3, I just want to give a shout out to folks out there and remind everyone that the deadline for submissions is this Friday, February 1, at midnight.

-Once again, posts about surgical experiences should come from a blog and should be submitted to anesthesioboist@gmail.com in the form of a link to the original post.

-I bagged the tentative theme of "the good, the bad, and the ugly." As often happens as a collection takes shape, the group of entries has acquired a character of its own, bringing other possible themes / organizational foci into view.

-I have received many good submissions but will likely not be able to include everyone's. If you submitted a piece and it doesn't end up in the carnival, the most likely reason is that the anthology took on a particular "personality" as submissions came in and not all the posts blended in well with the others, even if they were good posts.

Thanks to all who have submitted so far!

Virtues of the Chosen

I've seen so much anxiety through the years about being good enough to be chosen.

I've been through my share. Will I make it through this ballet audition? Will I get into a good college? Sheesh, I'm at Harvard - did they make a mistake admitting me? Will I find a good husband? How can I get a med school to even look at me? Can I get a residency in that specialty? What if they decide I'm not good enough after all and cut me out of the program? Will they want my essay for their collection? Will my boss like my work? Does my group value my presence in it and want me to stay for partnership? Am I good enough to keep doing this? It goes on and on...

Today's Gospel reading told the story of how Jesus chose some of his disciples. There seemed to be no rhyme or reason to his choices, on the surface. At our parish's family Mass - picture a sea of squirmy toddlers, restless pre-adolescents, and busy-looking parents all crammed into a subterranean liturgical space - our insightful deacon, during his reflection on the Gospel reading, highlighted four virtues that he saw as part of the "job requirement" for being a disciple of Christ.

What was great was the way he got the kids to consider these virtues. He asked for a show of hands of who practiced a martial art, then asked the kids which form they were studying (most, including my son, said karate).

Then he brought forth a mysterious black backpack, opened it, and asked the kids by what symbol they could tell if their teacher was a good martial artist. "His belt," answered one kid. Deacon P pulled out an array of belts of different colors from his backpack and, with a word of deference to the presiding priest, draped his belts over the altar so we could all see each color: white, yellow, orange, grey, and brown.

He reminded us that we couldn't expect to get from white to brown or black as martial artists, or as followers of Christ's teaching, without the following attributes:

-Patience

-Determination

-Courage

-Humility, which Deacon P held up as perhaps the most important.

He gave examples of why each was important in the martial arts - patience because training always takes time; determination because the road can be hard, full of aches and pains and mistakes; courage, because competing in martial arts almost always means facing loss or rejection at least some of the time; and humility, because of the importance of recognizing that personal glory is fleeting and an inferior source of motivation, and that true excellence is a gift earned through hard work and can't guarantee that one will always be at one's best.

When I think back to my training as a physician, and the day-to-day slog of just getting through it all, I say a resounding Amen to the good deacon's insights. I was emotionally beaten down at times and have no idea how I managed to keep getting up, except by using my family's support as a handrail, and by showing up every day no matter how tired, defeated, hurt, or uncertain I felt.

The same is true, though less intensely so for me, with music. Kyoko came over to my house for a make-up lesson yesterday and we got totally stuck on my silly A flat key and E flat arpeggios, which I need for the Corelli concerto we're working on in chamber orchestra. My left pinky just won't do what I want it to, bend the way I want, press with the strength I want. If ever I needed patience with myself, and humility, it's now, with these oboe lessons - but patience has never been one of my virtues! So I try, and I squawk, then I hit a perfect note, get through a lovely passage, then squawk again, and so it goes.

The priest good-naturedly allowed Deacon P to keep the belts on the altar for the rest of Mass, but gathered to one side, and reminded us with a twinkle in his eye that underneath all his vestments was a black belt to hold up his pants.

I thought to myself, there are Catholics out there who would be aghast at this departure from the rubrics of the liturgy, and who might even consider the belts a desecration of the sanctity of the altar, even though they are the fruits of human work, which have since ancient times been considered altar-worthy. I thought they were a fitting adornment for the scriptural lessons of today.

I imagined what Jesus himself might say to those who would gasp at the relaxed approach at this Mass and point disapproving fingers. I think he would say what he said 2000 years ago to the folks who were nit-picking about his dietary habits and breaking of sabbath rules: "Get over yourself." (Actually, his exact words were, "You strain out a gnat and swallow a camel*," but the gist is the same.)

I find it comforting that a teacher looked upon by so many as the holiest of holy men chose ordinary, stumbling, bumbling people to receive his teachings and continue his work. He must have known that they and their spiritual descendants would screw up royally, countless times. But he held them up and called them to be their truest selves - not because they were talented, brilliant, famous, powerful, beautiful, or rich, but because they were "good" enough, not in the way our society says people are "good enough," but in a much more real, deeper way. He had faith that they would grow in the patience, determination, humility, and courage that could help create in the world the never-ending work-in-progress he called "the Kingdom of God." I don't know exactly what that is, or what God is, or whether our human reaching for the idea of God is even valid. But my faith tells me that the efforts to build that kingdom are not only valid but also imperative, and I hope I grow to be "good enough" too.

________________________________________________________

*Jesus' original tone is totally lost in layers of translation, but I like to think that even as he admonished the Pharisees, he had a sense of humor and wit: gnat is galmah in Aramaic, and camel is gamlah... :) Though perhaps the admonition was already a well-known idiom in Aramaic...and with the New Testament authored in Greek, we're, alas, once-removed from the sounds, nuances, and word-play of what he originally said...*sigh*...

Amputation

Whenever I give anesthesia for leg amputations I always think of how horrific these must have been during the American Civil War, without anesthesia.

Today I helped an elderly man sleep through the removal of his one remaining leg, which had become gangrenous. He was old and tired and just wanted to die.

He had a DNR or "do no resuscitate" order, which we rescinded temporarily during the time period covering his surgical procedure and post-op stay in the PACU, the "post-anesthesia care unit" (known to most as the recovery room).

I dislike DNRs.

Or I should say, I find them merciful in the ICU, but I dislike them in the O.R. I dislike them not because I am against allowing people to die in peace. On the contrary, I am very much for allowing families to let their loved ones go, with as much dignity and comfort, and as little violence, as possible.

I dislike them because most of the people I have talked to who have them but who also need surgery appear to have a limited idea of what resuscitation consists of. It often sounds to me like they see resuscitation only as the invasive activity they see portrayed in the media.

[As an aside, I have to comment on medicine on TV, especially fictional TV shows, which seem to relish depictions of the drama of resuscitation. In televised medical dramas, sexy doctors, who all somehow have the time and energy to commit adultery with each other, spend exciting moments pounding on chests, applying electric shocks to defibrillate the heart, and performing internal cardiac massage, all with unbelievable rates of success. They make resuscitation look at times frenetic and at times almost glamorous. (I hereby uphold Scrubs as the notable exception to my view of medical TV shows; most are glorified soap operas, but Scrubs really GETS hospital life, I think, in a way that no other show does.)]

"Codes" as depicted on TV shows are often faster paced than most real codes but about as invasive and violent. This is what people don't want: the pounding on chests, rib fractures, cracking of the sternum, and subsequent lingering in the ICU on a ventilator for God-only-knows how long. I completely agree. If I code when I'm eighty-something, for heaven's sake kiss me goodbye, reel in the IV tubing, and let me die in peace.

The problem is, as I've written before, anesthesiology IS resuscitation. Many if not most of our interventions are acts of resuscitation. Securing the airway. Placing intravenous or intraarterial lines for monitoring. Giving a drug to boost blood pressure when, as is often expected, it drops some as the anesthetic is first delivered. Administering appropriate fluids. Changing someone's heart rate with medication, to protect the heart or try to prevent physiologic disturbances that that particular patient wouldn't tolerate. Applying an electric shock to someone who develops unstable atrial fibrillation under anesthesia. All these are acts of resuscitation that no DNR should curtail because they are applied in reversible situations, where resuscitation is expected to effect helpful change.

As I discussed the anesthetic plan with my patient's health care proxy, including the temporary suspension of his DNR, there was a comical moment when the nurse brought an old anesthetic record for me to peruse. It was the record from the amputation of his other leg, and I remarked, "Wow, this wasn't too long ago. Anesthesiologist did a nice job." Then I looked at the name to see who had done the anesthesia and saw my own name there in the box. Sheepishly I said, "Oh! It was me." The health care proxy and nurse both laughed.

We brought the patient to the room and applied all the usual monitors. I gave him the anesthetic drugs in what I hoped would be a gentle, layered pace, as well as some pain medicine and medicine to prevent nausea. The surgery was quick. I still find the part where the surgeon saws through the bone gruesome, even though I know my patient is unconscious. The surgeon handed the man's leg to the nurse, who wrapped it and tagged it and removed it from the room. When the wound was sewn shut and dressed, I reversed the anesthetic, removed the monitors, and wheeled the patient to the PACU, the contours of his body under the blankets now only visible over the top half of the mattress. He slept peacefully for the rest of the morning.

He hasn't walked in years. He has no family. Now he only has half of his body left and depends on others for the most basic functions. He's tired and he wants to die. I cannot imagine this man's suffering and loneliness. All I could think as I left him in tranquility in the PACU was, I hope people show me gentleness when my time comes. I hope through his pain he felt some tenderness and care from us. And I hope he can get his rest.

____________________________________________________

Photo credit: View of the "Old Man", a piece of driftwood that has been floating in the lake for at least 70 years. Picture taken 18 September 2005 at Crater Lake National Park. Taken from a file uploaded to Wikimedia Commons by user Llywrch under the licensed under the Creative Commons Attribution ShareAlike 2.5

Call for Submissions: My First Blog Carnival

I am honored to have been invited to host SurgExperiences #114, a blog carnival, right here, on Sunday, February 3.

I am considering entitling the compilation "the good, the bad, and the ugly," but there's no real theme.

Please send submissions in the form of links to current or past blog posts to anesthesioboist@gmail.com by Friday, February 1.

The current edition is up and running at Counting Sheep, hosted by Terry. Enjoy these tales of surgery after hours!

Shock Therapy

An elderly woman with difficulty walking came to our office accompanied by her daughter. I began reading through the woman's chart. She was there to have a preoperative evaluation for electroconvulsive therapy.

There are those who consider ECT to be the equivalent of snake oil, only worse: not merely ineffective, but in fact damaging to the brain, causing permanent cognitive deficits. But there are others who feel that ECT can be very helpful, even life-saving, for people suffering from intractable depression. In the elderly it is an especially attractive treatment option because of its quicker onset than oral medications and its avoidance of drug interactions. The procedure itself, however, causes great physiologic disturbances and brief but significant stress to the heart. A physically unhealthy person with the right combination of medical illnesses can be vulnerable to heart failure or neurologic effects as a result of the treatment.

As I looked at this woman sitting in her wheelchair and read through her list of medical problems - congestive heart failure, blood pressure issues, an EKG suggesting a compromised blood supply to the heart, and an increased risk of aspiration of stomach contents into the lungs - I began to get a bad feeling. I had just provided anesthesia for a couple of ECTs that morning, and I couldn't imagine this woman's body tolerating the violence of this not-entirely-benign therapy.

I imagined myself injecting the anesthetic into her veins, causing a drop in blood pressure that might put her weak heart over the edge. I imagined myself placing the mask over her face, and trying to ventilate her. It would be difficult, because of her age and weight. Moreover, with her aspiration risk, I'd be crazy to do it that way anyway; she would need a breathing tube. Then I imagined the psychiatrist applying the shock; the intense muscle contractions that would overcome her from head to toe, including her tightly shut eyes and clenched teeth, like a full-body grimace; and the aftermath (even if I were to give her cardiac drugs to try to mitigate the effects): a sudden increase in heart rate caused by an intense fight-or-flight response, requiring her heart to basically run a marathon despite a decreased blood and oxygen supply because of her heart disease. Not only that, but her heart would have to pump against greater resistance, because her blood pressure would also have shot up to potentially dangerous levels, perhaps 20% higher than her usual.

I started to talk to the woman and her daughter about my concerns. Her daughter bristled immediately and was clearly somewhat irate that I was putting a roadblock between her mother and the treatment for her depression. "She's had this done 7 times at another hospital," protested the daughter. That always makes my job harder - when I try to do my best to protect someone from dangers I foresee, but others have forged ahead anyway.

"You mentioned she was hospitalized for acute heart failure last fall," I said. "That's also part of what concerns me."

"Well, yeah, but she was still able to have one more treatment even after that," said the daughter, whose tone was sounding increasingly resentful.

I looked at the daughter incredulously. I was not only failing to reach her, to communicate my point - that I had to put her mother's safety first - but also failing to connect the dots for her: that ECT presented significant risks for a patient with severe problems and could be especially dangerous for an unhealthy heart, because it could actually precipitate more problems or worsen existing ones.

Then she came back with the statement that really, really, really irritated me, so much so that I was still thinking about it later that night when my husband and I went to bed. She invoked the name of the psychiatrist at our hospital who had prescribed two more treatments for her mother, saying, "Dr. Plath would NEVER prescribe something if he didn't feel it was safe for her!"

This is going to make me sound like a horrible person, but I really had to summon all my powers of self-restraint and graciousness at that point. I had to resist the impulse to retort, "Oh, yeah? You wanna BET?! Dr. Plath wouldn't even know the first THING about how to keep her safe during and after this."

Of course I didn't say that. Instead I said that Dr. Plath's focus was to treat his patients, but he wasn't an anesthesiologist and might not be entirely aware of the things the anesthesiologists and recovery room nurses would have to deal with after he left the building, which he invariably did immediately after the last shock was administered. We're left to deal with the headaches and muscle aches, the spikes in heart rate, the menacing blood pressure swings - in other words, the physical, moment-to-moment patient care. I was getting the feeling that Dr. Plath discusses little of this with his patients and paints a rosy picture of ECT as categorically safe and benign, as many major medical centers do.

ECT can be MADE to be fairly safe, but gentle it's not. The FDA has classified devices for delivering ECT in the highest-risk class of medical machinery, Class III. Yet, even the surgeon general describes the risks of the procedure in relatively bland language. He writes, "There are no absolute medical contraindications to ECT. However, a recent history of myocardial infarct, irregular cardiac rhythm, or other heart conditions suggests the need for caution due to the risks of general anesthesia and the brief rise in heart rate, blood pressure, and load on the heart that accompany ECT administration."

While I don't think it's right to demonize electroconvulsive therapy as people have in film, fiction, and other media, I think it's important to recognize that along with some very real benefits for certain patients, it carries substantial risk for some, doesn't guarantee recovery from depression, and can on rare occasions be counter-productive. Ernest Hemingway apparently blamed ECT for destroying his memory and thus his career, and of course we all know the tragedy of his life's end.

I am ambivalent about these treatments and participate in them reluctantly, embracing a self-defined role as protector against pain and harmful physiologic effects. It's the role I would want my own anesthesiologist to espouse if I ever felt depressed enough to seek this kind of treatment.

Addendum: As for our elderly patient with the heart problems - I referred her to a cardiologist (she had never seen one before). Her name appeared on the schedule the following week, but she did not appear, so either she hadn't seen the cardiologist yet, or the cardiologist had made other recommendations.


***

In 2001 James Kaufman coined the term "the Sylvia Plath effect" to describe the association between creative writing and mental illness. He writes in his abstract for a paper on the subject: "Although many studies have demonstrated that creative writers are prone to suffer from mental illness, this relationship has not been truly examined in depth. Is this finding true of all writers? In Study One, 1,629 writers were analyzed for signs of mental illness. Female poets were found to be significantly more likely to suffer from mental illness than female fiction writers or male writers of any type."

His choice of words seems to suggests that writers, specifically female poets, tend to go mad; the writing preexists the mental illness. I actually think it's the other way around. I think the innate brain chemistry preexists and gives rise to the propensity for creative expression as well as for mania and/or depression. Perhaps the neurotransmitter levels and combinations that allow certain individuals to perceive the world and express their perceptions in such extraordinary ways also carry with them the burden of manic, depressive, and/or psychotic thinking.

I am no Sylvia Plath, nor would I EVER want to be. I am quite happy, thank you very much, with my regular little life and regular job and regular family, whom I consider special beyond measure but who, thank goodness, are regular enough not to be over-the-top special, like the Van Goghs and Mozarts of our society. I am not a WRITER writer. But I remember that there was a time when I took antidepressants for a few months post-partum and found myself not only unable to write as much but also uninterested in writing so much. So my dim post-partum view of the world brightened, but I felt the loss of something else that I had loved. All that is years behind me, and I hope it stays that way, but it showed me that there's really some tremendous power in our neurotransmitters, and we need to give our brains the very best care we possibly can.

A Good Laugh On My First Call Night After the Big Trip (just had to share)

Many of my readers know that a while back I wrote this rant defending my sacred profession and trying to inform people about the nature of my noble work. Well...let it not be said that I cannot also laugh at myself a little bit. This video clip puts a lighter spin on the topic of "what it is we anesthesiologists do":

Splashdown

Reentry accomplished!

Sunday night, jet lagged and out-of-touch as we were, we didn't even realize there was a blizzard brewing until our good friends informed us over dinner. By the time we realized how much snow was expected, and what an intolerable, dangerous mess the morning commute would be, it was midnight. I decided to drive to the hospital and try to find a place to sleep there till morning rather than deal with the commute.

Thought it made for a looooooong day, it was a great decision. The morning commute was about as bad as everyone thought it would be, and the O.R. was backed up. I was scheduled to work with the chief of surgery, 7 cases in all, and had an extra case inserted into the schedule at the last minute, for a 91-year-old man in complete heart block who needed a pacemaker.

Every time I'm away for a considerable period of time I feel like I won't know how to do my job any more, but by the middle of the day yesterday the chief of surgery was apparently out at the main desk between surgeries expressing great satisfaction with my work, so I guess I still know something about anesthetizing people and moving cases along...

I know I should allow myself to give myself more credit, but no one's harder on me than I am, and that habit's hard to break. I hear that's very oboe-ish. I also know that the anticipation of reentry is always worse than the actuality, but that doesn't stop me from anticipating!

Going Home

Flying back to the U.S. tonight. Back to the cold, the pressures of work, the long, tough days with little free time...but also to friends, home, our own beds and showers, the familiarity of our regular lives. Change is always bittersweet!

The Gender Gap and Assorted Thoughts on Our Last Full Day in Manila

Toward the end of 2007 the World Economic Forum released a report entitled The Global Gender Gap Report. Permit me to celebrate (and maybe even gloat a little about) the fact that we Filipinos are in the Top 10 (out of 128 countries) for gender equality, along with 9 other far wealthier nations peopled largely by Caucasians:

Gender Equality Rankings 2007

1 Sweden
2 Norway
3 Finland
4 Iceland
5 New Zealand
6 Philippines
7 Germany
8 Denmark
9 Ireland
10 Spain
11 UK

31 US
51 France
91 Japan
126 Pakistan
127 Chad
128 Yemen

We've had women professionals in our country, with fairly equal male/female ratios, for DECADES, since at least the 1950's. There were female musicians in the Manila Symphony in the 30's. Women have enjoyed positions of authority for years. When female judges, doctors, lawyers, business executives, and generals order their male officers around, the men pay attention, don't think twice about the women's gender, and "just do it." I don't know exactly why it's so different in other Asian/Latin countries or why the U.S. can't get its head out of its proverbial nether regions when it comes to race and gender. Maybe I should ask the two women presidents we've had.

***

They don't do this much back in Boston, but somehow closer to the equator they decided they felt like going ice skating. My heart still beats a little faster, à la high school girl with a huge crush, when I watch my husband skate.

***

If I had remained in the Philippines instead of moving to the U.S. I would have loved to open a business like this: Fully Booked, a well-stocked bookstore that imports best-selling titles from abroad. This branch had a coffeeshop with floor-to-ceiling windows that let in a lot of natural light. We spent part of our last full afternoon here. It's amazing how just walking into a big book store and smelling that books-all-around-you aroma either quickens my pulse with instant excitement or quiets it down with a prompt sense of calm. Why is that?

***

The American war cemetery is a peaceful and moving place to visit, especially for a part-Filipino, part-American family. Carved into a stone wall near the entrance to the circular memorial are these words: "In proud remembrance of the achievements of her sons and in humble tribute to their sacrifices this memorial has been erected by the United States of America. 1941-1945." So many suffered on our shores, and so many suffer still from senseless violence, torture, and war. I hope someday those who choose the way of hostility gain the courage to choose nonviolence. It's hard to be optimistic these days, but as I wrote before, there's a difference between optimism and hope, and for the moment I refuse to give up the latter. And to those who are now following in these soldiers' footsteps giving their lives on foreign shores...forgive us; we know not what we do; we can only offer our thanks and the sentiments of our minds and hearts.

Ensaymada Day

My Tita M had me over to connect me to my Pampango family heritage and learn a little about making our delectable ensaymadas.

My great-grandmother Brigida made ensaymadas and sold them on the church steps after Mass for a living (in Angeles City, though, not at the church pictured, which is the church of San Agustin in the old city of Manila). She had 17 children, 4 of whom died, and by all accounts she was as good a woman as good can be. By the time people asked her how to make her delicious, golden ensaymadas, inflation had made her answers hard to decipher: cinco centavos of this and diez of that no longer bought the same volumes as they had when she was working full-time. She lived to be about a hundred; her funeral was the first I ever attended.

What I can say about the process is this: it's not that hard, but it's not that easy, either. There's a lot of kneading and waiting, at least three separate dough risings, and a great deal of rolling out, rolling up, weighing, and buttering. Oh, is there ever a lot of buttering. I think I have to try never, ever to make these for myself!

The best part of the whole process was story-telling with my Tita M. She's smart and funny and a pleasure to be with, and her stories kept me either wide-eyed with interest or laughing my head off all day.

I've appreciated the chance to reconnect with my native culture this trip. I often focus on the things I criticize about it - the tendency for people to be a little too enmeshed, and at times infantilized; the lack of privacy; the occasional small-mindedness; the petty hostilities, class separation, and judgments. But in these past 3 weeks I've been able to rediscover what I appreciate about it: the way people help each other during tough times, are generous almost to a fault, are so ready to laugh, and are comfortable with touch and affection. Here a man can walk home with his arm around another man's shoulder simply because they are friends.

In our particular town, too, thanks in part to the efforts of our close family friends who are in charge of a lot of commerce in the area, Muslims and Christians seem to be able to coexist peacefully. Perhaps that is the most striking image I'll carry with me: that of the flea market crowded with People of the Book living and working together with no need for violence.

Filipino Food III: Drinks and the Dark Side (Or, Liquids Clear and Not-so-clear)

As we approach the end of our time in the tropics I thought I'd touch on some beverages, soups, and scarier food items that are not exactly what you'd find in your local Dairy Queen.

First, our hot chocolate. This is not your watery, cocoa-from-a-powder stuff, a la Swiss Miss or Hershey's. This is the thick, chocolatey, melted-a-chocolate-bar-into-a-hot-drink, Spanish stuff. It comes in round tablets that we stir into milk laboriously over a hot stove with a batidor. We serve it with churros or pan de sal or ensaymadas or just drink the yummy stuff by itself (less commonly).

Our favorite citrus fruit is the calamansi. It's closer to lime than lemon, quite tart, but has a distinctive tase all its own that I just can't describe. Its juice, cooled and sweetened slightly, is a refreshing way to start the day.

The best mangoes in the world naturally make the best mango juices and shakes (green or ripe) in the world. It'll be hard to say goodbye to our golden treasure, the Philippine mango.

Ginumis is a textured treat made by layering pearls of sago (tapioca), colored cubes of gulaman (gelatin), perhaps some tiny balls of fruit, and tasty toasted pinipig (immature glutinous rice that has been pounded into flakes), then pouring panocha syrup and coconut milk over the stuff and eating the concoction parfait-style, with a spoon ,or stirring the whole thing together into a delicious slurry before consuming. It's a yummy melange of tastes and textures, very refreshing in the afternoon.

Ice cream is western. Sometimes I find western foods here that are even better than what I've had "Stateside" (my cousin Gaita's successful restaurant chain, Cibo, serves the best pasta dishes outside of Italy, cooked al dente every time). The reverse is not true, however - Asian food is never better there than here. What makes our ice cream so rich and creamy is carabao milk. I guess it's kind of like eating mozzarella di bufala in Italy. The milk from these draft animals is pure heaven. So ice cream made from it is...well, heavenly.

Comfort food for the fluish comes in the form of lugaw, similar to Chinese congee, or its cousin, arroz caldo, a similar rice porridge with some added seasonings.

Some Americans have heard of our other common soup dish, sinigang, with its tart tamarind base.

But most would be put off, as I am, by dinuguan...pork blood stew, ew, ew, eeeeewwwww.

And perhaps also by callos (stew of tripe, sausage, chickpeas, and assorted meats), though perhaps the Spanish genes in me make me less wary of the latter.

There's a lot of stuff on The Dark Side of Filipino cuisine. I'm so sheltered I probably wouldn't even recognize most of it. The scariest thing I'll eat (and enjoy) is the very un-scary bagoong. Fish heads, whole crabs, chicken feet, and certain parts of lechon (roast suckling pig) give me that treacherous tickle at the back of the throat that threatens to turn into spillage...How un-pinoy of me...

TV host Andrew Zimmern has brought some of our truly frightening fare to light on his show Bizarre Foods, while Fear Factor put this little delicacy on the international stage: balut, or fertilized duck egg. My husband was gonna try to eat one once...but chickened out, so to speak, when he detected the embryonic feathers interlaced with the egg white as he was peeling the thing...

So as not to end on that note, I'll sign off with this food picture, a jeepney alongside us last week carting a load of fresh pineapples from a plantation in Cavite into Manila. There's nothing like having walked on the very earth in which your food was grown, then eating its sweet fruit freshly picked.