Day 22: August 26

Today marks our last formal interview in China! We left our hotel in the morning for an hour and a half drive to the Zhaoqing No.2 People’s Hospital. When we arrived at the hospital, we were first introduced to the cath lab of the hospital. All of us were required to wear foot covers, masks, and surgical gowns before we entered. Some of us snuck in some selfies while we put them on!14203095_10154629386011162_2323313209917450806_n

While we were in the cath lab, the departmental head of cardiology gave a brief overview of the history of their hospital. They began doing pacemaker surgeries in 2000 and decided to build the cath lab in 2004 to allow for more pacemaker surgeries once the demand was high enough. He shared with us a few key insights of his own including his own observations that most Chinese cardiology operation rooms do not have surgical cautery machines (aka Bovies) to make the initial incision. He told us that most cardiology OR’s in China only rely on surgical knives. When we asked if high costs were the reason they were not used, he responded that they were not; the real reason was that the Bovie units took too much space in the room. He attributed the longer post-operation rate of pacemaker surgeries to this.

Afterwards, we continued to the meeting room upstairs for the formal interview. We started receiving answers that were very similar to hospitals that we visited earlier, so during this interview, many of us opted to ask more specific questions about possible areas of focus for our project. For example, many other hospitals have already noted that patients were afraid of having a foreign object in their body forever, but this time Taryn asked the hospitals what they thought was the best method to address this. The hospital thought that a sample pacemaker with a live demonstration of its functionality would be able to show patients that the pacemaker was not very big and clear up confusion on how the pacemaker works. Dan also asked the doctors if they had ever tried convincing potential pacemaker patients by connecting them with other patients that have already had a successful pacemaker implant. The doctors agreed that this might be a good idea, but that patients might be suspicious about hospital bias and that many pacemaker patients would not want a third party to know about their implants.

And just like that, we were done with our work in China! Once we got on the bus and pulled away from the hospital, Katie cheered, “We’re done!”. After getting back to the hotel, we had a rushed final goodbye dinner for both Dan and Rachel (she was leaving early to visit home). Then, the rest of the team celebrated the end of our interviews with some karoake!

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Day 21: Aug. 25

For our hospital visits today, we broke into two groups. One group went to the nearby Guangzhou Chinese Medicine University Hospital in Guangzhou and then went a few hours away to visit the Zhuahi People’s Hospital, a class 3A hospital, and the other group left at 6 am for Meizhou to visit Yuedong Hospital.

The Chinese Medicine hospital was a great experience. The combine western medicine with Traditional Chinese Medicine for their diagnoses and treatments, and explained to us that it was important to have the old as well as the new. This was definitely the most beautiful hospital we have seen in China. Each floor represents one of 24 Chinese seasons, and there is a courtyard with statues depicting Chinese medicine. Patients were already walking around the grounds before the hospital opened for check in. Speaking with the doctors, we found out that patients who come in with indications for a pacemaker, but do not need it immediately, will be treated with medicine instead. These Chinese herbs cause the patient’s heart rate to go up to normal, so the patient and doctor both believe they do not need a pacemaker. Patients coming here also do not want to have a machine inside them. They are very loyal to traditional medicine, and skeptical of Western Medicine in general. They believe Traditional Chinese Medicine cannot harm them because it is natural, and Western Medicine could be harmful because it is artificial and made with chemicals.

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This visit was especially useful because we got to speak with patients and their families in a speed-dating fashion, as they kept being ushered in before we finished up with the previous one. The first we spoke with got a pacemaker and was very pleased with it, but was also devoted to Chinese medicine and this particular hospital, and continued to receive medicinal treatment along with his pacemaker. The next two patients we spoke with rejected pacemakers because on traditional medicine they had no symptoms.

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The second hospital was very impressive. The EP we spoke with was very open about what was good about their hospital as well as ways it could be improved. It was an interesting case, because in this area most of the price of a pacemaker is reimbursed, so cost was not the main factor. She told us some techniques she used to communicate with patients needing pacemakers to educate them, and emphasized the need to tailor what kinds of things you say to specific patients. We went to the CCU and the cath lab, and she pointed out the long distance between the two. Patients had to be pushed on transport beds outside down the road to go back and forth, even in the rain. We think this hospital would be a great one to collaborate with!

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Meanwhile, the other team visited the YueDong Hospital, affiliated to the Third Affiliated Hospital of Sun Yat Sen University, at Meizhou, which was about 400 KM from Guangzhou. The team left at 6 AM and reached the hospital around 10:30 AM. After meeting with the Director of General Administration of the Hospital, who gave us a good introduction tour around the Hospital. This is a county hospital that was affiliated with the Sun Yat Sen University in 2014. This move was initiated by the city government with a 1.3 Billion RMB funding. This was used to build infrastructure and procure devices like C-arms. They have a capacity of 700 beds and are planning to expand to a 1500. However, they are critically understaffed and can currently handle up to 500 to 600 beds. The main reason pointed out by the Director was that people who now required the qualification demanded by the esteemed Sun Yat Sen University would prefer to work at a much higher level hospital. The team then visited the Cath Lab, which was built after renovation which had a Philips C-arm, which was also procured after the affiliation. A senior cardiologist, Dr. Zeng had just finished Coronary angiography for a patient with acute myocardial infarction.

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The team then interviewed Dr. Zeng and the Director. This hospital performs around 10 pacemaker implants (including ICDs and CRTs) every year, majority of which are dual chamber pacemakers, with the help of a senior Doctor from the University. Whenever they diagnose a patient with symptoms, they communicate with the corresponding surgeon and try to organize the surgery at the earliest possible instant. In case of emergency, they have been granted the permission to contact the surgeon by phone. The surgeon then travels at the scheduled date. It was interesting to note that the travel expense for the surgeon was reimbursed by the University and the surgeon could also earn a consultation and surgery fee. It was estimated that the surgery could be arranged between 2-5 days after diagnosis. They proactively work on trying to have all the relevant cases for a surgeon pushed to the day he travels to this place. There is a heavy emphasis on education and training in the surgeries that are performed by the surgeons from the University. Since Dr. Zeng was an expert in PCI, he pointed out the differences between stent and pacemaker procedures – the challenges with handling leads, sterilization, and the slow learning curve due to the comparatively low number of patients and expected this hospital to independently perform simple pacemaker procedures in a couple of years. A lot of the other common challenges pertaining to patient mentality and awareness of both patients and physicians were pointed out. Currently they are building a team around each main surgeon and have a holistic approach to start performing surgeries independently. They opined that they could do a lot more surgeries even with the current system and were of the opinion that patient awareness and affordability were the main reasons and that starting to perform the surgeries independently would not drastically improve the numbers.

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After the insightful conversation, Dr. Zeng had to leave and the Director invited us for lunch at the hospital canteen, during which he explained in further detail about the relationship between the hospital and the University and pointed out that this was a trail for more such similar collaborations between large established hospitals and county hospitals. He was happy with the progress of this Hospital and reiterated his confidence in this approach.

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The team then interviewed a nurse who had an early lunch. She recollected the last two patient cases who had pacemaker implants and both were uncommon cases. The first was undergoing treatment at a larger hospital for acute heart failure and was diagnosed with bradycardia there. She was sent to this hospital immediately after her surgery there, since this hospital was capable of performing implants. The second patient was undergoing treatment for MI here was and recommended for pacing therapy post-surgery. She then explained about the 15 day post-op care that patients were given at this hospital and recollected some common concerns for patients who needed pacing.

After exhausting all our questions to the nurse, the team thanked here and looked around to try and interview more healthcare providers. To our surprise, the hospital seemed deserted, partly due to the fact that it was lunch time. The team was able to observe a lot of counters and nurse stations not being used and realized the criticality of the understaffing at this hospital. The team then left for our hotel at Guangzhou.

After reaching our hotel, the team was joined by Dan, who felt much better by then, and they visited an Indian restaurant. The group reached the place by metro. Everyone ordered the Indian dishes they could recognize. The starters that Arvind ordered were particularly spicy and Thai especially had a tough time handling it. He was sweating throughout the dinner. After having dinner, the group rushed to the hotel to join Dr. Yazdi and the other group to have an overall discussion about the project.

Day 20: Aug. 24

Today was a full day of exciting visits! First, we traveled a few hours for our lunch meeting with many members of the cardiology team at the People’s Hospital of New District Longhua Sheazhea in Longhua.

Their cardiology department was started just three years ago, and they have developed a diagnosis room, unique to their hospital. They serve a younger patient population, 20-40 years old, because of their location, but still do single, dual chamber pacemaker and ICD implants. One cardiologist, Dr. Xie, who has a lot of experience working in community level hospitals explained that education and ability to diagnosis ECGs is the main limitation in pacemaker implants in China. Later discussion surfaced some main areas where patients drop out in the care pathway: Class 3 hospitals due to financial problems and during follow-up because patients are moving around constantly. Overall, referral up from a Class 1 or 2 hospital was not expressed to be a problem, but the main drop out area is in fact happening at the Class 3 hospitals. When we asked about how we can reach the patients lost before they get into the care pathway, they explained how it’s an education and social problem that must be addressed, for both community doctors and patients alike. They also told us about a slogan started in 1990 that was well publicized and helped with patient awareness: “if you experience chest pain, then go to the hospital”. Towards the end of the meeting, they made a lot of references to PCI (percutaneous coronary intervention) at their hospital, how although it is similar to pacemaker implantation, patients are more accepting of PCI because they predict they will feel better right away and know the surgeries are more common. After our working lunch, we quickly sped out to our next visit at Lifetech, a company recently partnered with Medtronic.

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We met with Dr. Lepeng Zeng, the Chief Medical Officer of Lifetech. He first provided us with a great overview report on the Chinese pacemaker market from 2014. It was data he had collected and complied and will be a great resource for us in working on our project once we get back to the states. During the interview, we were able to gain a lot of interesting insights and a new perspective on similar questions we had been asking the cardiologists all month. He emphasized the importance of temporary pacemakers in permanent pacemaker adoption, as well as the need for cardiologists who can do the implant. As of 2013, there were only 1,000 implanters throughout China, thus Dr. Zeng emphasized the importance of physician education. Yet in the end, he said it’s “like a puzzle, (you) need to get every piece” referencing the fact that there are many aspects of low pacemaker adoption in China. After a while of discussion, Dr. Zeng showed us around the new facilities where they will soon be manufacturing pacemakers. The labs were beautiful and extremely clean!

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Then we headed back to our hotel / the mall, where we split up and got dinner: most of us going to a Hong Kong inspired restaurant, but our two vegetarian friends, Arvind and Dr. Yazdi, went for Burger King. We were upset in ourselves that we broke our Wednesday night McDonald’s tradition, but wanted time to go to Muji so that Taryn could buy out all their pens, before our Medtronic weekly conference call meeting. During the call, we had a very nice discussion with Nathan, Jon, Julia and even Dr. Yong Cho was able to join us on the call! We filled them in on some more general trends we were noticing and how Guangdong province has differed from the two other provinces thus far. After our meeting, we headed to bed, another long day ahead tomorrow!

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Day 19: Aug. 23

Today, we drove quite a few hours to visit the Qingyuan People’s Hospital. We started with a tour of their cath lab, which had an angiography procedure underway. We noticed again that they use washable sterile drapes instead of the disposable ones we always see at Hopkins Hospital. Then, we briefly interviewed their head nurse, standing in a hot side room still under construction. After Tessa downed three mini cups of water, we headed upstairs to a small meeting room where we talked with all the cardiology doctors.

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The interview started out a little rough as the doctors all tried to talk over each other and the team’s questions were scattered. The doctors started out with many technical improvements for pacemaker products, such as a flatter but wider canister, more flexible leads, a longer sheath, a smaller canister, longer battery life, rechargeable pacemakers, leadless pacemakers, and “just lower the price.” After getting past one doctor’s adamant assertion that cost was the biggest reason why Chinese patients were not receiving the pacemakers they need, we were able to confirm that pacemaker diagnosis and implantation are limited by physician education and patient education. This contributes to patients not understanding and seeing the value in getting a pacemaker.

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After the interview, we walked next door for a fancy dinner with some of the cardiology doctors and two Chinese Medtronic reps. The first dish placed on the automatic lazy Susan was some sliced chicken with the chicken’s cooked head positioned to stare right at you. We ate other, more enticing dishes, like Chinese ice cream cones stuffed with a meat-vegetable mix, as we played the funny game to grab food with our chopsticks before the lazy Susan rotated past our reach. Most memorable from this dinner was the strong wine alcohol served in tiny glass goblets. The doctors started enjoying themselves as we discussed strange topics, like why none of us wore glasses and how popular laser eye surgery is in the U.S.

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As we left the restaurant, the team bonded with the two Medtronic reps who spoke some English and looked way too young to work at Medtronic. One of them, Jackie, drove back with us to Guangzhou and gave us some great information and advice. He also said that Thai looks like he’s 26 years old, which made Thai very happy. On the bus ride back to the hotel, we were able to have a brief interview with Jackie, who was very honest and insightful – also just generally in love with pacemakers, as seen in the photo below.

Day 18: Aug. 22

Today we continued our collaboration with the Gaozhou People’s Hospital, and went in for interviews with: the head surgical nurse in cardiology, junior doctors in cardiology, and a post-op pacemaker inpatient. The hospital is a county level Class 3A and does a little over 100 pacemaker implants every year.

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We had a very insightful conversation with the head nurse, as she provided many insights regarding patient reimbursement, the use of temporary pacemakers, and her opinions on the most common reasons for rejection: awareness, affordability, post-op management, old age, and the severity of symptoms. Even more insightful, she shared her husband’s cousin’s pacemaker story. She explained how he had been concerned about if the pacemaker can truly fix the disease, if there are side effects, and the fact that it was a foreign body inside of him – yet in the end he was very compliant, after some convincing. He had first come to this hospital in Gaozhou, but had his daughter bring his ECGs for a second opinion at a larger city level hospital in Guangzhou before agreeing to accept the pacemaker. The nurse then showed us the Cath labs where pacemaker implants are done, as well as the leads used for temporary pacemakers.

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Then we split up into two groups: (1) Dan, Victor, Taryn, Thai to interview a pacemaker patient and (2) Katie, Tessa, Rachel, Dr. Yazdi, Arvind to interview a junior doctor and nurse. The patient and her daughter were very shy, but we were able to learn about her story and processing through the care pathway to receive the pacemaker. Although a large financial burden, with only a 50% rural reimbursement policy, the daughter said it was just important to make sure her mom was safe and healthy. The patient had not known about pacemakers before being diagnosed and followed a “whatever you say doc” attitude, coming to this hospital because of the strong cardiology department. Towards the end of the junior doctor interview, we also learned about how some patients thank their doctors with beautiful banners with words of thanks or a poem (show below).

Next, we went to lunch at a nearby restaurant with traditional northeastern Chinese food. The lunch was a hit and Katie was finally happy with our eating abilities. Then, we headed out on our long journey back to Guangzhou, where we would be for the rest of the week!

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Day 17: Aug. 21

Today was another day of substantial travel, as we had to head to Gaozhou about 5 hours away for our next cardiology team interview. First, we grabbed an early lunch at a Vietnamese place nearby with mysterious ‘avocado’ custards and a little bit too minty of spring rolls (but they were pretty).

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After the long ride, we arrived in Gaozhou and went directly to dinner with many members of the Gaozhou People’s Hospital cardiology team and the Medtronic sales representative in that region. It was a very formal dinner and didn’t consist of a typical Chinese business dinner, where everyone gets a bit too tipsy. Regardless of their more casual intentions, we tried to get as much as we could out of the interview, while trying to eat enough of the interesting entrees to not seem rude.

We really had two mini-interviews going on during the dinner, one side focusing mostly on pacemaker certification for doctors and their motivation, the other side getting advice about what areas our project should focus on. The head of the hospital explained that the main areas to make an impact are: (1) increasing flow of patients in and out of larger hospitals (2) helping county hospitals with diagnosis and (3) assisting more Class 2 hospitals with implantation. The two group strategy was also helpful because we were able to ask similar questions to different doctors on opposite sides of the table, and as a result we often heard some interestingly conflicting information.

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After many thanks and goodbyes until we saw most of them again at the hospital tomorrow, we then headed out to the hot springs hotel we were staying at for our night in Gaozhou. We had yet another near-death experience together as we drove through horribly muddy backroads in our bus to the hotel and then had mutual thoughts of confusion when we saw main roads as a clear path to get to the hospital. Regardless, we finally got there and rushed to change and go to the hot springs before they were closed for the night. In the end we only were able to get a few minutes of hot spring time, spending a lot of it trying to decide on which one to go in: the lavender one, the big one, the one with the water slide, etc. The team headed upstairs to get to sleep before tomorrow’s early hospital visit, a bit disappointed in our minimal hot spring time (the reason we had picked this hotel), but still happy to say we had done it at least!

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Day 16: Aug. 20

Today we headed onto our next destination, Guangzhou, in Guangdong Province. Before our flight though, we went to Maan Coffee for some mindmapping and refreshments. Caught in a downpour trying to get back to the hotel before leaving for the airport though, Dr. Yazdi was spotted using his Macbook Air to shield himself from the rain.

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Then it was off to the airport, splitting up from Jon who was going back to the states already. The week with him went by very quickly and we were sad to say goodbye for now. We will miss his weird verbal outbursts and Vietnamese swearing.

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Once we arrived at Guangzhou, we directly met up with the next awesome Medtronic engineer, Dan! Our initial feelings about Guangzhou were: HOT. We were sad to leave the cool, breezy Kunming life, now having to deal with what felt like >100% humidity.

After we arrived at our hotel, good ole Fraser Suites again, we went out for dinner at a
local Hong Kong inspired restaurant that felt like an American sports bar with fútbol jerseys everywhere. Soon after, we retired, sleepy from another day of travel.

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Day 15: Aug. 19

The itinerary for the day was to travel to the beautiful Dali (2nd most beautiful place in the province, according to our guide, Ms. KitKatKan), but first Xiangyun, for a Class 2A hospital visit at the Xiangyun County Hospital. A lot of us were excited about this visit, mainly because we had been waiting to converse with a different level of hospitals that possibly had more hurdles regarding pacemaker implants. We were thankful to the ER department of Medtronic, who was with us in Chengdu, and helped organize this trip, after understanding our actual requirements.

Xiangyun County Hospital was one of the few Class 2A hospitals in Yunnan that were capable of implanting pacemakers. They have implanted 26 pacemakers so far – all of which were dual chamber, except for an ICD. All of these were Medtronic devices. They had a good collaboration with a larger city hospital, from which an established electrophysiologist would come here and perform the implantation – which was observed and partially performed by the doctors from this hospital, as a part of their training process. They also mentioned they mainly avoided single chamber pacemaker implants at this hospital in order to avoid pacemaker syndrome. Around 50-60 patients were diagnosed with symptoms of bradycardia or tachycardia, at the hospital every year. There is a reported 80-85% dropout rate after diagnosis in this hospital – mainly due to affordability issues, especially given the fact that majority of their patients were covered by the most basic rural health insurance which forced extraordinary out of the pocket expenses on patients who couldn’t afford the procedure and pacemaker costs in the first place. This was followed by other unique insights on the mentality of the patients who visited the hospital and the challenges that this hospital faced in becoming independent.

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We were then presented with a unique opportunity to interact with a patient who was contemplating on receiving a pacemaker. He was ~60 years old, has other health conditions and had come with his wife, who suffers from chronic back pain. He mainly wanted a few more years to support his grandchildren who were 6 and 13 year olds, as well as parentless due to unfortunate events.  The patient wanted to be able to add more money to his savings for them, which was currently sufficient to help them through middle school. His monthly income in the form of Government support is 200 RMB for three months, for the entire family. We really sympathized for the patient and his family, wishing we could do something more to help him afford a pacemaker at that moment in time. Later, the doctors informed us that this is unfortunately a fairly common situation with many of their patients in this rural area.

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After this, we thanked our hosts and proceeded to Dali. We had a very delicious lunch with a view and this helped some of us to de-stress after that interview. The green tea cake was particularly a hit amongst all of us. The whole, fried shrimp was a particular dare among most of us. The essence chicken was brought back and we had some classic dumplings to satisfy our weak American stomachs.

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Then we went to a special area in Dali, where a we roamed around for a couple of hours, shopped a little and returned to our van by 7:00 PM. Most of our time was spent trying to pick the prettiest hand-crafted soap flowers we could find and taking selfies on top of the huge pagoda with breathtaking views all around. We also were able to witness all the street vendors having to rapidly clean up their sidewalk business when the police neared. There were also many temptations to buy cool flowy-colorful pants, yummy looking street fruits, and rent mopeds.

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Most of us slept after getting into the bus, exhausted from the long day. After a grueling drive, we finally reached our hotel in Kunming by 1:30 AM.

Day 14: Aug. 18

The team woke up early for a visit at the 1st Affiliated Hospital of Kunming University. We met with two doctors and a nurse; Dr. Li and Dr. Liu both spoke English so we could conduct the interview without translation! It was probably our best interview because we could speak directly to them, cover twice as much information and get honest, insightful answers from the two junior doctors.

This was the first hospital to admit that the number of patient beds is a limiting factor and that patients often need connections to get a bed at such a large hospital. Dr. Liu told us a story about a patient who had her pacemaker removed after three months due to anxiety and insomnia. Then both doctors emphasized the importance of a patient’s psychological health in addition to their physiological health, but explained that in China, psychological issues carry a bad stigma and are associated with insanity, so patients may not seek treatment.

We also learned more about the poor doctor-patient relationship, which began in the 1980’s when the Chinese government launched a “medical revolution.”  The costs of healthcare were rising and the government decided that patients needed to begin paying for some of their medical expenses. Of course, patients were upset about this change, but the blame for this shift was placed on doctors and hospitals for charging too much, creating a lack of trust between patients and doctors. Over the past 30+ years, this mistrust has grown; most patients want a second opinion for medical diagnoses and treatments, doctors conduct excessive testing for unlikely medical conditions to protect themselves from liability, and throughout the country, almost once a month, a doctor is killed or violently attacked. This really put things into perspective and made us appreciate the American healthcare system.

For the future, both doctors hoped that more pacemaker procedures could be done at rural hospitals; this would improve affordability for low income patients and allow larger hospitals, like their hospital, to focus on more complex procedures.

After the interview, we had to opportunity to interview a patient. Katie, Rachel and Taryn interviewed with an older man who is on his 3rd CRT device. After 9 years of symptoms which progressed to heart failure, two syncope episodes, and two recommendations for pacemakers, he finally got a pacemaker and has had two replacements since. His wife chimed in as well expressing that they are happy with the results but concerned about affording more devices in the future.

After returning from the hospital, the team settled in to work at Maan Coffee, a unique cafe. There were real trees looming over wooden tables with fancy armchairs to sit in. Colorful chandeliers reflected the sunlight making rainbows all over the tables. Shelves filled with many books lined the walls. Better yet, they served extravagant coffee drinks, waffles with ice cream, giant French toast, and interesting sandwiches. Plus, they gave you a stuffed teddy bear to take back to your table until the food arrived. We stayed here for at least four hours…

All our hard work deserved a shopping break. We walked past blind people offering massages and explored a Chinese traditional medicine store, where we couldn’t muster up the courage to pretend one of us had syncope. When crossing a busy street, Katie made it to the other side, the rest of the group couldn’t even make it past the moped/motorcycle traffic, and Dr. Yazdi ended up hanging in the center divider with the local police officer. We attempted to take a jumping picture, found a roller skating rink, passed by lots of cooked bugs/worms, bargained at street shops and, as usual, ended up at McDonald’s. We headed to Korean BBQ dinner, crossing that same street and passed a goldfish in an open water bottle.

For dinner, they cooked our food on a grill built into the table, but not before bringing red hot coal buckets to go underneath — HOTTEST IN MY LIFE. We ate hot noodles, cold noodles, and delicious but unidentified meats. We ended the night with another Carrefour supermarket visit, overwhelmed by the infinite yogurt choices and struggling to carry all our purchases home because we don’t know how to ask for plastic bags.