A Four Week Medical Rotation in Ecuador and the Lessons Learned

After a month of rotating in a third world country in a public health clinic needless to say there were many things I learned and things that I now appreciate much more about medicine in the United States. Here are a few of those things:

WHAT I LEARNED

Clinical skills: In a setting where you lack basic amenities like x-rays, quickly ordered labs, and sometimes even proper sutures and syringes you consequently pick up some of the more basic and readily applied skills. Some of these skills include listening more accuraely for pathologic breath sounds, HEENT exam, listening for fetal heart tones with a stethoscope, Leopold maneuvers to assess the baby’s positions, and most of all, wrestling resistant pediatric patients and still getting a full physical exam. Stuff John Cena would take notes on.  In one day I learned more about pediatric physical exams than my entire peds rotation back in Chicago.

Exposure to pathology: Being exposed to so many sick people with advanced diseases really helps sharpen your clinical diagnostic skills. Not only were there large number of sick patients but people with advanced disease because they would not see a physician earlier at the start of their symptoms.  Also living in a pathogen laden environment like Ecuador people tend to pick a lot more of those disease causing bugs.

Improvised skills: Sometimes you just don’t have what you need. But this doesn’t mean you can’t continue being a doctor. Working as a future Army physician in a deployed setting I’m sure I’ll have to face this same situation and Ecuador really opened my mind to what you can do when you don’t have everything you want.

Relying on physical exam versus studies: We didn’t have access to instant xrays, ultrasounds, and practically no CTs or MRIs. Since we couldn't just send a patient to get these special tests done you have to not only become very competent in your physical exam skills but learn to trust them and to create a treatment plan that won't leave you second guessing yourself later.

Swimming without the safety net: Lastly the big lesson I learned was working for proper patient care when you don’t have that safety net of a physician around you. There were times when we didn’t have an attending physician looking over us, or even in the room. Times like this we would have to be the main doctors for the clinic and only during tough cases we would consult the medical director... if he was there. The first time this happened I was absolutely worried, however by the fourth week we felt comfortable and confident enough to run the clinic and do our best as senior medical students. And yes, I’m pretty sure that would have been against all sorts of laws back in the United States but hey, welcome to Ecuador.




WHAT I APPRECIATE MORE

First and foremost, electronic medical records: Being able to turn on a computer and find all sorts of doctor notes, labs, and imagining on a patient is incredible! If we had a patient who even knew what medications they were on we were ecstatic!

Sterile fields: Can someone please get me a sterile field? Every time I had to suture a patient it was a new experience. Sometimes if the wound was large enough and we lacked saline solution I would have to wash out their wound with the backyard hose (seriously) and then rinse it with sterile saline solution and then get to work in the clinic to sow them up. And even then keeping all your tools and suture line sterile was a nearly impossible task. Sometimes you just have to combine a little bit of careful hand movements with a whole lot of prayers.  I call this Ecuadorian sterile field.

The importance of structured learning and continuing eduction: Becoming a doctor is not simply getting a degree after four years of medical school. It’s more than just a three or more year residency. It’s learning every day and bettering yourself to become a competent and efficient doctor. Ecuador in some regards lacked this where I was located. I worked with some great physicians who constantly pushed themselves to be better physicians and it showed. Others you could tell lost that continual education and actually made me worried when watching them practice. For me going to a residency where I have competent mentors means that much more to me, and after I graduate I hope to continue learning from those better than myself.

Having access to labs, imaging, and results make you a better doctor: Very often we didn’t have access to these things. When a patient walks into your clinic they have a diagnosis and it's your job to figure it out and treat appropriately.  So many times you would long for that one test that would confirm your suspicions, but instead you have to combine your physical exam findings, personal experience, and a whole lot of doctor intuition.  When you have access to these diagnostic tools it helps greatly in being able to identify syndromes and symptoms.  Eventually as you get used to seeing patterns you might not even need to order those same tests.  Unless you practice in the United States and our litigious society and end up practicing defensive medicine, but that's a topic for another day.

The medical experience I had in Ecuador was unforgettable and priceless. I am so happy that I was able to work alongside the physicians at El Centro de Salud and learn so much from them. It made me a better physician. It strengthened my confidence. And it gave me a deeper perspective of medicine and it’s application. I can’t wait for the future opportunities I will have to serve as a physician in another setting like Ecuador and know that this rotation will serve to make me better than before.

Balance and Companionship

We humans are a very social species. Even from the very beginning it was said of Adam that “it is not good for man to be alone”. My time here in Ecuador has taught me this lesson, a lesson I have had to learn many times over. Each day as a medical student you have your usual shift at the clinic. Each day is unpredictable where you might just be dealing with children with colds, and another day you might find that the doctor on duty isn’t going to show up and you now have a woman in tears holding a convulsing child in her arms at your door. By the the end of the day it’s easy to just want to go home and rest. The problem I have found is when this goes on too many days in a row.

One thing that makes my situation here interesting is the location of the home at which I’m staying. Located out of town in a comfortable neighborhood but with a bus that only runs up to 8 pm and miles away from the city of Quito it’s easy to feel isolated. With my daily responsibilities as an international medical student it’s not hard to let this become the main focus of each day, however if this remains unchecked it’s easy to start neglecting the other areas of balance in life.

About five years ago a group of close friends and I were talking about this very subject. We compared the four main areas of life balance as rings interconnected. Each person may have different rings but ultimately they are interdependent and attention must be paid to all of them in order for the four to stay connected as one. My four are:

- Friends and Family
- Health/Fitness
- Work/Education
- Spirituality

Being a hard worker and self motivated it’s easy for me to keep the last three in check, but for some reason the first one can tend to be neglected. Perhaps it is due to my personality type or having grown up rather introverted but whatever the reason is I know one thing too well; if that first one is not sustained all four suffer. It requires active work and reminders to make sure it gets its proper attention.

These past three weeks I have had some incredible experiences with some great people. Definitely highlights of my time here. But in contrast I will admit there are also nights after several long, stressful days when this secluded location and stress get to me. But thank God for our modern communication to be able to stay in touch with people irregardless of distance! Phone and video calls with family have been essential in keeping my moral high. Messages from friends are like breaths of fresh air. But for me the most important thing is having a loving companion who also goes out of her way to make sure I know I’m loved and is by my side even though we are separated by thousands of miles. But it hasn’t been without its challenges. Being separated by 6 hours means that often when I get home she is getting ready for sleep and when I wake she may already be out exploring some place in Europe and out of wifi reach. But we make it happen, even if it means setting an alarm for 1:30 am to leave a mostly incoherent voicemail or her staying up late into the night so we can tell stories of everything happening in our lives.

Being away from those you love really shows you how much they truly mean to you. The more space and importance that person takes up in your life the more you become aware of it once separated. However when that place is again filled by the person you care about how great is that reunion? I personally can’t wait to be reunited by the girl I love and have two incredible friends join me in exploring the beautiful city of Quito and it’s surrounding lands. After all for me that is what life is all about; incredible experiences and sharing them with those you love.

I guess if there was anything I would hope a read may get out of this is to question yourself:

What are the main areas of balance in your life?
Are those areas being met?
And what can you do to make sure that they are?

Also go tell someone you love just how much they mean to you. What could go wrong? ;)

Exploring Otavalo And Its Lagunas

For anyone visiting Quito Ecuador one place that you must not miss is Otavalo located about 35 miles north of Quito.  Otavalo is an incredible town where every Saturday they have a large artisan market that fills the streets and plazas with vendors selling ponchos, blankets, jewelry, wooden decorations, grains, fruits and so on.  In addition to the incredible items you can find in the market it is the people themselves that make it what it is.  Many wear traditional clothes with women wearing traditional white embroidered blouses, dark skirts and different colored shawls whereas the men may be seen with white pants, braided hair, dark colored ponchos and felt hats.  

Three fellow travelers and I started our weekend Otavalo adventure at the Hostal Otavalo Inn located inside the city.  It's the only hostel I've ever stayed at where they actually cook breakfast for you in the morning consisting of eggs, bread from the local bakery, fresh juice, and coffee or hot chocolate.  All this plus wifi, comfortable beds and friendly staff at a grand total of $12/night.  

We decided that for the first day we would explore Lago Cuicocha, a lake found west of the Otavalo formed by rivers flowing into the crater of an old inactive volcano.  To get there we took our 35 cent bus ride to Quirago and then contracted a truck to carry us up to the park for $5.  The hike around Lago Cuicocha truly is amazing.  At a total distance of 8 miles round trip you are never without an incredible view.  All around Lago Cuicocha are breathtaking views of the Andes with multiple peaks over 15,000, and on the other side of the trail is the immense crater lake with two islands formed from a slightly younger inactive volcano.  However for me one of the greatest views on the hike is Volcan Cotacachi which is just north of the lake.  With a summit at 16,220 surrounded by rocky spires and often blanketed in clouds it may be one of the more daunting peaks I've seen with my own eyes.  After a little research I discovered that most treks stop before the final couple hundred feet to the summit due to the technical skill required.

For as much as I enjoyed Lago Cuicocha the real highlight of our Otavalo weekend for me was Laguna Mojanda.  Where Lago Cuicocha is easily accessible with many amenities close by, Laguna Mojanda is remote and you must plan accordingly.  From Otavalo you can contract yet another truck that will take you up to the Laguna.  Instead of paved roads you get a thirty minute bumpy ride in the back of a truck up stone roads.  As you ascent higher and higher into the Andes you will be surrounded by incredible landscapes with farms creeping up steep mountainous inclines, cows that must been part mountain goat to navigate the precarious terrain, and dense vegetation.  Laguna Mojanda is the result of two inactive stratovolcanos and just like Lago Cuicocha it is the fed by rain and rivers to a volcano crater with no outlet. 

There are a few things that make Laguna Mojanda so remarkable for me.  First, the landscape.  High altitude grasslands surrounded by rocky cliffs and rolling hills with the laguna in the middle.  Next, the remoteness and seclusion.  You can hike and explore and sometimes feel like you're the only ones there.  A sharp contrast to life living in Chicago.  Last, the weather. Even though at high altitudes the weather can change in an instant, going from blue skies to heavy rain, it also leads to ever changing scenic landscapes and colors.  Options for adventure in the area include hiking around the perimeter of the laguna, venturing to the smaller laguna which is towered over by steep jagged cliffs, or attempt for the summit of Fuya Fuya with a summit of just under 14,000 ft.  While there we also saw a few others camping beside the coast of the laguna a few doing motocross.  Finally if you're feeling adventurous I definitely recommend a dive into the lake. Cold cold mountain goodness.

Whether you are looking for culture, food, or high adventure all can be found in Otavalo and its surrounding lands.  Fortunately I will be able to explore this remarkable place a second time once I am joined by my friends from Chicago and girlfriend Daisy who is currently solo adventuring across all of Europe.   Until then we'll see where my adventures take me next.

Swimming In Deep Water

A favorite saying of mine when I was a personal trainer is that "no growth of a human being takes place inside their comfort zone."  In medicine that is called having an attending doctor with you aka your safety net.  Well Wednesdays at el Centro de Salud they take that net away.  Not only do they take it away they pour gasoline on it, set it ablaze and then point at you and laugh.  Okay maybe not that extreme but pretty close; they don't actually point.  

Wednesday is when we students run the clinic.  Last week it came as a surprise to me but now it's something I have come to expect.  The first time we were in charge I was left completely drained by the end of the day having seen patients nonstop with the other two medical students from 8am to 4pm without a break for lunch.  Also, even though I'm pretty fluent in Spanish, having to keep one side of your brain working at full speed to speak clearly and then the other half being used to differentiate possible diagnoses and come up with treatment plans can be pretty exhausting.  Fortunately this week we three brought our A game and it definitely showed.

"No growth of a human being takes place inside their comfort zone." I repeat this phrase because there is so much meaning to it.  In medical school you are constantly pushed and placed just outside that zone.  It's easy for some to want to stay inside its warm boundaries and say "well I know how to take care of the common cold so I'll just treat those patients".  But then in walks a febrile young female patient who you soon diagnosis with pyelonephritis (infection of the kidney) and you thank God that you paid attention during that nephrology lecture.  

True story by the way.  

It felt really good to know that I had worked hard enough on other rotations so that with clinical accuracy we were able to ask the important questions, rule out other serious pathology, and get her a treatment plan, which I must say surprised me more than her diagnosis.  Normally for pyelonephritis in the United States you are admitted to the hospital on IV antibiotics.  After consulting the clinic director we put her on Nitrofurantoin pills and ibuprofen..... Not the big guns I had been hoping for.  Bienvenidos a public health in Ecuador.  Sometimes you just don't have what you need.  Maybe that should be our slogan....

Wednesdays in Ecuador are when I swim, the alternative being to sink.  They are the days when my clinical skills are put to the test and I have to deal with a strong reality: mistakes can cause harm.  It adds a pressure to how I treat patients but it is also what will make me a better doctor.  

Wednesdays here at el Centro de Salud you leave your comfort zone behind and you go to work.

The Bare Essentials

If there’s one thing that this whole experience will teach me, it’s how to be a physician even when you don’t have all the cool gadgets. I can’t say everything is completely FDA approved, but it seems to work out just fine down here.

Lesson 1: When a child comes into your clinic with a temperature close to 40 C (104 F) you have one response: cool them down quick. I learned this lesson three times today from three pediatric patients who had temperatures just under 40 C. We give the Paracetamol and wet their bodies with a rag and warm water so that through evaporation their temperatures lower. This all for the purpose of presenting febrile seizures, which is no bueno.

Lesson 2: If you don’t have a Doppler ultrasound, or any ultrasound for that matter all you need is a good stethoscope, able hands, and great hearing. Today seemed to be OB day at the clinic for the community and the physician taught me how to do Leopold Maneuvers in order to figure out the position of the fetus and how to pick up heart tones with just a stethoscope. Pretty cool stuff, but I still have a lot of practice to do there.

Lesson 3: Calculating dosing for several medications based on body weight of the patient.

Lesson 4: Apparently a quick way to test someone to see if they’re allergic to Penicillin is to just take the Penicillin/Lidocaine mixture you’re going give as an intramuscular injection and put a drop in their eye. I guess if they are allergic a red eye is better than a systemic allergic reaction, which might kill you in our clinic due to our lack of resources. This is also no bueno.

Lesson 5: Tonsils can get big. REAL big.

Lesson 6: After seeing never ending furious hoards of sick children how to subtly pick up on pathologic breath sounds. Looks like this rotation is going to make up for my poor pediatric rotation after all.

Lesson 7: I apparently have some kind of super human immune system because there is no reason why I shouldn’t be sick after I have been coughed on by so many sick children. Now how do I use this power to fight crime?…..

So I Guess That Makes Me The Doctor

It would seem that after two days of experience working in the clinic that a grand counsel decided that it would be best to let the medical students run the show today. Either that or the doctor that was supposed to be the attending decided that he would just leave a note pad of pre-signed prescriptions in his place. Either way today’s dream team consisted of an Ecuadorian senior medical student (Juan Carlos), myself (mostly proficient in Spanish and figuring things out) and another fourth year medical student from Australia (Brianna, still trying to get a hold of this whole Spanish thing). It looks like my two days of experience were to be put to the test. A moment of sink or swim.

Fortunately all anyone gets in Ecuador is a common cold and they’re happy with some Paracetamol (similar to Tylenol) and go their way right? The answer to this is “wrong”. Not even an hour had gone by and we already had a pediatric patient of about two years who was brought in emergently with a deep scalp laceration on the back of his head. Also it’s never going to be an quick easy job to suture a wound when the patient is actively fighting you. Juan Carlos spearheaded the suturing while the mother and Brianna held down the child, which in the meantime the nursing student from Boston holding a light source came close to passing out. Luckily I can shine a light and cut sutures with two separate hands. Didn’t even learn that from a book. And of course it wouldn’t be an Ecuadorian experience if we had all the right supplies, so say hello to fat needles for local lidocaine injections and suturing. I will never take for granted a small 25 gauge needle again. Fortunately after a lot of hard work and screaming everything was taken care of and the young child started to calm down which was followed by one of the more tender moments I’ve witnessed. The two year old, still slightly stained by blood from the head wound, saw his sister come over to his bed, then he held out his hand to take hers as if to say, “I’m okay”.

Today was a humbling experience. Even though I have learned so much throughout these past four years days like today show me just how much more there is to learn. Rarely do you get moments like this so early in your medical career where you’re the one running the show. I definitely feel motivated to continue developing both my clinical skills and medical Spanish. I’m happy that I’ve had enough learning experiences to prepare me for this rotation because it is unlike anything I have done yet, especially when after seeing dozens of patients you get a women who is deaf, can’t speak, and has an infected ingrown toe nail that needs to be treated. This place is just full of surprises.  Also I think today half of Ecuador coughed on me... more or less.

La Clinica

Is that pus coming out of his ear? The answer to this is yes. But lets not jump ahead. I figured that rotating in Ecuador at a community clinics was going to be full of surprises and I would be thrown into it the thick of it, and today I came to find that I was absolutely correct. And what better way to start a new rotation than getting lost am I right? After going to where I assumed to be the correct meeting place I started to question my logic after almost an hour or so. I guess I might as well head over to the clinic and find a call center close by.

After spending my twenty five cents on the bus ride I walked up to the El Centro de Salud, which having been open only about fifteen minutes was already full of patients hoping to see a physician for their many different complaints. I began wading through the groups of people trying to find someone official looking in a white coat and after having found several I quickly realized something; no one knows I’m suppose to be here. Which led me to plan B: to the call center! Fortunately I was able to get a hold of Maria Agusta, the main coordinator for the international program, and we had a plan; I was to wait at the clinica and do what I could until she arrived.

El Centro de Salud in Tumbaco I later came to find is the busiest clinic for this area, spanning several different small cities, towns, and neighborhoods. Once the doors open there is no end to the number of patients waiting to see a doctor until you finally have to start turning people away and ask them to come back the next day. Fortunately my time as a Spanish speaking missionary and Spanish medical interpreter prepared me well for this experience. The medicine wasn’t the hard part. Learning how it is practiced here was the true challenge.

In the United States we have vast amounts of medical resources, research, education and specialists. If you have a problem, chances are you can find someone to treat you and they can give you several different options for treatments, often in the form of medication. I quickly learned that this was not going to be the case. Resources are limited so conservative therapy is often the treatment of choice. Fortunately most of the complaints some form or other of gastroenteritis of unknown origin or a upper respiratory infection. But then you get others who are really sick or have an acute injury. In walks a patient with a venous stasis ulcer that needs to be debrided and have his dressings changed; however there are no scalpels left in the clinic or Kerlex (dressing used to wrap around wounds) and you’re just going to have to use the back of scissors and just tape a bunch of gauze over the now clean wound. Sir you seem to be bleeding profusely from laceration on your finger. Lets stitch you up! However we have run out of 4.0 and 5.0 suture kits so lets just use on of the big 3.0 suture and hope everything comes together well. And is that pus coming out of that child’s ear? (see, we’re al caught up now) Ah so this is what happens when infectious otitis media is left untreated and it actually causes the tympanic membrane to rupture and now there is pus leaking out of your ear hole (technical term). Despite all of this the clinic moves forward, you help out in everything, and practically everyone leaves humble and very grateful for your service.

One great lesson I have gained from all of this is that the administration of healthcare has no perfect system. It must adapt to each situation and patient. Students here get trained in so many ways because there is a good chance that they are going to see anything and everything, so they must be prepared. I have no doubt that when I serve as a physician in a deployed setting I must be able to adapt the each unique situation and my time here will leave me more than trained for those moments.

Well time to rest up now. Who know’s whose ear is going to be leaking pus tomorrow.