Puyo

I´m in Puyo now for the second month of my program. Puyo is a small city about 5 hours away from quito by bus. It is actually nicknamed "el corazon de la selva" which translates to the heart of the ranforest. It actually kind of boarders the amazon so it´s not quite deep in it but it is defintately on the edge. I´m staying with two other med students in the house of the doctor that we are working with out here in puyo. His house is pretty nice for an ecuadorian house out here. I have my own room which is nice and share a bathroom with the family of the doctor as well as the medical students I am with. In the small backyard there are actually a couple chickens, some baby chickens and also two ducks. I think they eat them, but i´m not really positive. Last night we did eat duck but i don´t know where it came from - whether it was the market or from their back yard. This week for the first few days we work in various clinics for a few days. This morning we were supposed to have a lecture on snake bites and leishmaniasis from a local doctor but there was some sort of emergency so he had to cancel. This weekend we have a long weekend off because the following weekend we actually go trekking into the jungle around manta about 2 hours from here. I´m not exactly sure what it entails, but i know we got out hiking for about 4 days with a guy who is going to take us to some small villages as well as teach us about the medicinial uses of a lot of local plants and things. I´m not sure where we are sleeping but I do know that I am taking a sleeping bag as well as my mosquito net. at some point next week we are also doing some malaria work with a local organization where I think we go out in the community and maybe spray for mosquitos or try to eliminate standing water, as well as maybe take blood samples from some local people to monitor the types of malaria in the area. The rest of the time will be spent at some clinics and hospitals. at least one clinic that we spend 3 or 4 days at, is a couple hours away and i think deeper into the jungle. its some sort of missionary clinic where there is only one doctor at most and they apparently are appreciative of the help. And so far i remain healthy.(knock on wood) not too many problems yet so we´ll see...

Canoa

So Im now at the only internet in town in the little coastal town on the pacific, and its the worst internet connections thus far in ecuador. For anyone who has emailed me, sorry but it takes like 20 minutes literally to pull up my account and so i cant really write anyone back now and this entry will be somewhat limited and unedited and there will definately be no photos.

I finished up in the ER this week and now have this week off before going to puyo to do tropical medicine on the edge of the jungle. So on sunday I traveled a little north of quito to mindo, a town known for its waterfalls and also oddly enough its butterflies. It was a pretty good day trip although it rained a lot. I got to see some pretty amazing waterfalls and do some hiking which was pretty nice.

monday I left to head to the coast. My goal was to get to canoa, a small town on the coast I heard of from a couple of british and american bartenders in quito. I left in a bus at noon on monday and had the nicest bus ride i have ever had in ecuador, traveling 8 hours to a town called bahia. the bus was $9. I stayed the night in bahia in a mildly crappy hostel for $5 and then the following day caught a ferry for free to a town across the river and then caught a 1 hour bus to canoa for 35 cents. The bus ride was pretty interesting. this was the oldest bus i have ever been on, more like a school bus and it was all rusting out everywher and the seats were wet. merenge music blared and people jumped on , dumping 50 pound sacs of flour on the floor and random other things. Another guy loaded up some rebar on the roof before getting in and then we took off for canoa. When arriving in canoa, I got off the bus and was just standing looking at the two dirt roads with some half built buildings beside the beach. just then the 30 feet of rebar slammed to the ground after someone tossed it off the bus and just barely me.

the town is pretty much a coupld of dirt roads with a few different hostels, a couple bars and convenience stores. it used to be a fishing town but has become known as a surfing spot and is starting to attract tourist, but it is not well known and there are not many people here. There is 16 km of pristine beach that stretches from canoa to san vincinte and its beautiful. Much like southern california - huge white sandy beaches surrounded by cliffs and some rocks out in the water on one end. It s georgeous. there are probably two blocks of buildings along the shore and thats it. I go running on the beach and when i get away from thos e two blocks its just the beach and cliffs.

The hostel I'm staying at bambu - has a bunch of bamboo shacks, a bar/restaurant, and surboards to rent. The room is $8 a night, actually one of the most expensive rooms, and surfboards can be rented for $2. Dinner costs $3, a corona $1.50 and a white russian $2. Other than that there are lots of hammocks to lounge around in. I've been here a day and a half now and i have never been so burnt. I think the last time i was this burnt was when i was 12. But its amazing. I wake up, have some crepes with fruit and some coffee. go for a run. read my book in a hammock. go surfing for an hour or two. And then kind of lounge around drinking, eating and reading in a hammock. I am trying not to get burned, i have 48 spf waterproof sunblock but it seems to do nothing.

The only downside is there is dengue here. its endemic. So i wear a lot of Deet and sleep in a mosquito net at night. Im also taking doxycycline for malaria prophylaxis which doesnt help with getting burned by the sun. So thus far on my trip I have been exposed to bacterial meningitis, Tb, and quite possibly malaria and dengue.(at least i'm in regions where it is endemic)

So im staying here through friday and surfing and then taking a night bus back to quito. I am not sure if i will get back on the internet here this week as it is expensive and crappy and slow. but well see.

Im going to go now and try and do some surfing as the sun sets so I dont get too much sun when i do so.

Last weekends hike

So last weekend while in otavalo, we went on this amazing hike just outside of the town of otavalo. It was a hike around the rim of an old volcano that blew it's top a long time ago and has since been filled in with rainwater in what was once the volcanic crater.

It was one of the most amazing hikes I've ever been on. In the middle of this gigantic lake of rainwater that collects in the crater is a mountain of sorts that I guess is leftover from when the top blew off. But now it is covered with vegetation as is the rest of the crater so it's just beautiful. see below

The rim of the volcanoe formed cliffs probably 1000 to 1500 feet above the lake that were pretty sheer and there were mountains all around the rim as well. During the hike it was incredibly sunny with the exception of when cloud cover would blow by. Being so high up the clouds would actually roll through the peaks around the volcanic rim which was pretty spectacular. see below:

The hike around the rim ended up taking a little over 3 hours.

The day after the hike we walked for about an hour outside of town to see a local waterfall that was pretty amazing:

Ecuadorian ER part dos

Connected to the portable heart monitor is apparently the only defibrilator in the ER. Only it seems that the only problem it has is that it doesn't really work. In a code today they went to defibrilate the patient, and well it just kinda didn't fire. I don't know it was kinda weird.

Overall though it's an amazing experience there. I have been working a lot with one of the residents and he's great to work with a very intelligent. Its pretty amazing how much they can do with so little.

The other day when I arrived a patient came in overnight who was 24 and had been shot twice in the neck. One bullet exited and the other shattered a vertebrae and lodged itself in the cord between c6 and c7. It was sad obviously but also amazing to see how he was managed. He wasn't in any ICU bed because it was full and the only monitor was the mash era heart monitor. He had been on dopamine overnight because following his injury he couldn't maintain his pressures so he was on dopamine until they filled him with enough fluids to compensate for the dilation of his vasculature following the lesion. I was impressed that here you don't call up a pharmacy and order dopamine, you know the needed dose, you calculate how much to add to a bag of normal saline and then you make it up yourself.

They do have some central lines, but only single lumen lines. So they drop in a single lumen line and then rig up multiple splitter to run in multiple fluids or draw off blood as they need. The most amazing thing I saw was how they measured the central venous pressure. So in the states you just hook this gadget up to one lumen of the central line and then plug it into the computer and it gives you a readout of the CVP. Here they just connect a tube to the line, tape the tube to the IV pole so it runs up vertically and then they have a piece of cardboard with centimeters hashed off so you can read the CVP off it. It was so simply done, but obviously how it was originally done and it worked which was really cool.

This was an incredibly sad case for me though. This 24 year old guy had his cord severed between C6 and C7. Which means he'll essentially have some feeling/function in his shoulders and parts of his arms, but other than that is a quadriplegic. One normally breaths using your diaphram and the muscles between the ribs, but in this situation you lose the fuction of your rib muscles and only have your diaphragm. So he couldn't breath quite as well as someone normally would, and you can also tire out your diaphram in this situation so that you can't properly ventilate yourself.

So in the United States, If you had a patient with worsening respiratory status you would intubate them(stuck a tube down their airway) and put them on a respirator if need be to help them breath. Then over time you would try to wean off the ventilator if possible. People in the US survive with these types of injuries and I had just been assuming it wouldn't really be that different here because I hadn't really thought about it.

I realized it was different when the doctor I was working with told the girlfriend/wife of the patient, that unless he improved in the next 20 minutes they would stop supportive care and pretty much let the guy die. I stood around talking with a number of the doctors who explained that they don't really have huge ICUs to support patients like this, and that they don't have the money are resources to deal with the complications down the line. The resident who was working with me turned to me and said "in the US do you have floors like this, full of respirators to keep patients like this alive?"

I was mildly confused at first and then just simply said that yes we do.

The sad thing is that it pretty much comes down to money. In the United states, the way we practice medicine is we pretty much do everything within our power to treat people as long as there is a chance for benefit and it's what the patient wants. Here, and I imagine in the majority of the world, it's different. There is not much money, which limits medicine, and unless you are independently wealthy if you get a bad injury such as this you simply die.

It was upsetting to see, because I have never seen someone die for lack of resources. It's upsetting to see someone die because they are poor and they live in a poor country.

Ecuadorian ER - part 1

So I began working in the ER this week and I really enjoy it. It´s amazing how poor it is in the ER but the physicians are actually really good. It´s a large ER in a public hospital and serves as an ER for the poor in Quito. When you walk to the entrance it looks incredibly run down, with paint falling off the building in places and anywhere from 20 to 50 paitents just standing around outside the waiting room or in the waiting room to get in. To enter you have to get through a closed glass door that has a guard stationed by it on the inside. The guard has a bullet proof vest, a sidearm and he wraps a heavy duty chain around the inside door handles to keep it locked. So unless a patient is being seen they are literally locked out of the ER.

When you enter, it´s ridiculously dirty and shabby. Paint falls off the walls, syringes and old medical supplies just kind of little the floors and under patients beds. There are some patients just kinda of wandering around with an IV in place and holding onto an IV bag in one hand. The ER is divided into a number of medium sized rooms probably 10 yards by 5 yards in size. There will be anywhere from 1 to 5 patients in each room. Each patient is normall on a bed or stretcher of some sort with no sheet, pretty much nothing with them. Maybe one will have an IV in place. When you´re working patients just kinda get rolled into the room without notice. It might be someone with a broken leg or arm, someone who what shot in the neck or back, someone run over by a car... You don´t really know until you grab the piece of paper they are rolled in with and read it.

In a room of 5 patients there will be a resident and maybe a med student and thats it. The nurses sometimes take blood, but more often its the resident. The doctors take all the vitals themselves and pretty much do everything and they are actually quite good. I´ve been working a lot with one and he is very intelligent and a great teacher.

The rooms are barren, there are a couple sinks, a lightbox and some broken out windows along one wall and maybe a blood pressure cuff and one IV pole. There is no monitoring equipment save one heart monitor that literally is the oldest piece of medical equipment I have ever seen. It looks like it belongs in the TV show mash.

More time in the clinics

So I've been in a second pediatrics clinic following the first week of working here and it's quite different than the first. The first was exceptionally poor, a public clinic in Quito and the second is a private quite modern clinic.

In retrospect the care at the first clinic was actually quite impressive given what they had I think. It was an exceptionally poor clinic as I described before, they had little money and they saw tons of patients with limited resources. While limited I still felt like the care of the physicians was very pretty good.

This second week at a private clinic has been quite different. Its has pretty much all the amenities of an american clinic, and even has access to the majority of the labs that we would order in the states(with some exceptions). They are still limited by expenses though.

However while there is more ability to fund things the medical care has been far more lacking from my viewpoint. Like anywhere in the world and in any profession the quality of care that one receives can be variable, and I'm finding that here. I've been quite unimpressed with the approach and knowledge of the current doctor that I have been working with. Our interviews never last more than 2 minutes whatever the chief complaint, and our physical exams are incredibly lacking. For instance take the following scenario the other day:

A 2.5 year old male presents with fever and cough for over one month. Recently the cough has been more productive. The patient was treated with an injection of penicillin at some point recently and previously had also been treated with some bronchitis with no effect for presumed asthma(despite no wheezes). Neither previous treatment had any effect. The patient continues to be febrile and cough. The interview which was being conducted by the physician was completed at this point.

Ok time out... Tb is pretty much endemic here, and this is a case that to me, pretty much screams you must rule out Tb, yet there were no questions asked about exposures, contacts, living conditions etc. ok time in.

So the exam was pretty much limited to a heart, lung and abd exam, which revealed little. Chest was clear for the most part and no real sign of infection was seen except a mildly red throat and fever.

Tx: amoxicillin for a presumed pharyngitis and or pulmonary infection caused by something not covered by penicillin.

Here was the conversation that ensued between the doctor and I:

me: "ummm... Do you ever worry about tuberculosis in your patients?"

d: "not really, see because this is a private clinic, all my patients are from middle class families. Families that provide their kids with good nutrition who do not live in poor crowded conditions. Tb is a disease of the poor, in kids who are malnourished."

me: " Yeah its more common in those situations but you could still get it despite good nutrition and a good living environment right?"

d: " Well this child has had the BCG vaccine."

me: " hmm ...from what I have read the BCG vaccine helps to prevent miliary Tb and menigeal Tb but doesn't really prevent pulmonary Tb"

d: "No it prevents pulmonary Tb"

me "........."

d: "Yes so this patient doesn't have Tb we're going to give him amoxicillian and cover the organism that wasn't killed with penicillin."

me " yeah so i was reading the pediatric infectious disease book last night and it said that the
BCG vaccine doesn't prevent pulmonary Tb........"

d: "yes it does, this patient doesn't have Tb"

me: "oh...."

New photos and lost photos

New photos from the trip have been added that I took with my camera into past posts so feel free to check them out.

Also it seems Mac was robbed on the trail to macchu pichu and lost his camera so all of the photos from the jungle were lost.

Hopefully I will get some more when i go to work in puyo later on

First Days at clinc

So I worked wednesday and thursday at a local clinic for the poor. Both days I worked just in the morning with a family doctor seeing mostly children. We show up at this clinic at about 8am. The clinic is located at the base of one of the mountains surrounding quito and pretty much serves the poorer people in the neighborhood - and if you're poor in quito you're really poor.

When we show up there about about 40 people waiting outside and they pretty much file into this shack of a clinic that is located on the top of a muddy hill on the side of the mountain. They all sit in one run down room with 4 or 5 benches that look like church pews and then they wait. I see patients with the doctor and as soon as one leaves the next one comes in. The clinic is stripped to a bare minimum. the clinic rooms have concrete walls with paint flaking off everywhere, there are flies buzzing around the whole time and there really isn't much in the way of medical equiment except the basics.

Because there just isn't really any money at the clinic we don't really order hardly any tests. If a kids hands seem to have pallor, they give them iron. If they have a stomach ache and won't eat they are given mebendazole to clear out parasites that are presumably causing it.

Clinical skills seem good but they don't exactly practice evidence based medicine. For a woman who had 3 days of vomiting and diarrhea presumed to be food poinsoning, we gave pancreatic enzymes to help her diarrhea and no antibiotics. Another woman who came in complaining of 4 days of lower abd pain, fever, and a little bit of blood in the urine we gave mebendazole for parasites and nothing else. No UA was done, no gynecologic exam, etc. It's a little wierd at times.

Plus by law doctors are only allowed to work 4 hours a day here. It's unclear why. There seem to be too many doctors - some cannot find any work at all, and the economy is bad. One doctor told me they made this law after it was decided that doctors have to deal with so much emotional issues and difficult things that they are only allowed to do it 4 hours per day 5 days a week. I'm not sure if that is true though. Overall though I'm not sure exactly what the deal is.