Loose Ends

6-26-08 – Esmeraldas, Ecuador

The other night in minor surg we saw a patient referred to us by the doctor working up front in clinic. We through a chest x-ray up on the light box then called the first doctor in. “Why didn’t you treat the bullet?” He scrambled because from a mile away you could see its outline on the film. “What,” he turned to the patient, “why didn’t you say anything”. We all laughed, patient included, because she had had it for 18 years. Apparently in Esmeraldas you can find bullets in chest x-rays that have nothing to do with the chief complaint.

Today at lunch I met someone whose spoon was stolen. She used a tongue depressor instead.

The other night a woman was slashed. She was carrying her one-year old son who also had a lacerated back. Question 1: who attacks women carrying babies? Another guy walked in with a stray bullet through his lower leg, but he was stable and we were out of beds so I had him sit in a chair. After the baby and his mother were treated, I got around to seeing the guy, but by that time he had a rotten attitude – upset he had to wait. Selfish bastard. We exchanged a few words, then, disgusted by his temperament, I saw someone else instead. He didn’t like this. After the interim patient, I filled out requests for radiographs and wrote the guy some prescriptions, but he didn’t want my help – he shouted something too fast for my understanding and walked away. Recap: because I didn’t like him, I didn’t treat him promptly. Question 2: what does this say about me?

Speaking of people who didn’t want things from me – yesterday I wrote out a request for a rubber tube to put in the bladder of a motorcycle accident patient. The doctor signed it and added a few medications to the list. But the guy in the stock closet didn’t much seem to care that a patient was suffering: “You can’t put two people’s handwriting on one ticket,” he barked – then handed over only the rubber tube. This is not a hospital rule – he just wanted to flex his wimpy-ass muscles and feel important for fifteen seconds. That’s disgusting.

Two women who were raped for three hours came in at 8p. We gave them birth control but didn’t have HIV/AIDS medication, so they sweated the night wondering their fate, waiting for an external clinic to open. I found a bench and sat and thought and hurt – this is also disgusting.

“Everyone talks about the ability to stand blood and gore, to live through tragedy, but the real quality needed is altruism. ... Without it, the job becomes a relentless tour of the worst parts of life. Without some form of altruism, the job is unbearable” - Louis Schillinger. "Blood and guts". New York Times book report 5/25/2008.

Million Dollar Baby

6-26-08 – Esmeraldas, Ecuador
My head says to avoid politics, my heart tells me I cannot. Not when the hospital is in the shape that it is: lacking both equipment and staff, having leadership but without direction, personnel without intuition - having patients but lacking healthcare. The finger pointing is relentless, but it makes little difference because if you pick any hole and look through it you can see all the others. Most people fault the director, who runs the hospital like the warden of Shawshank Redemption – crooked and unpredictable. They do this for a number of reasons, the top three being it’s easy, it’s fun and it’s true. My vote is with the majority; I carry a chip on my shoulder from the night we wanted to use the OR and couldn’t. A few weeks ago he also docked ten percent of the salary of a friend as a fine for something stupid. And then last week, in front of patients, he started name-calling and bullying, telling a doctor he was stupid. He’s the guy everyone loves to hate - that’s why I am excited to tell this story.

It was about mid-morning on an average day when Falcones, an intern, pulled me aside. “The Minister of public health is here – go tell her what you think about this place”. Falcones knows I want to see things improve – he works with me on guard number one (of a four-guard rotation) and was there for the Morbidity and Mortality meeting. So I stepped out – but only to step into a roomful of doctors jumbled around a Chinese woman, the Minister, who was going from bed to bed getting the low down. In the back of the room were some official looking people, well dressed and with mustaches –government types with clip-boards and pleated pants. I still didn’t understand who this lady was, but she must have been important because everyone was there, so I wiggled my way to the front where Safadi was diplomatically letting loose. Our friend the director was clearly nervous, or pissed – it was hard to tell the source of his unease – but his knees were wobbly and he tried to counter what was said. The Chinese woman couldn’t believe there wasn’t a laryngyscope in the ER apart from the one Safadi brings from home, or that when the surgeon is in the OR, there isn’t the staff to cover and patients wait for hours to get stitched. Suffice it to say there were a lot of things she couldn’t believe – and before she left we had a verbal commitment for a million dollars.

Safadi bought some suds for his pals and we celebrated that night: Pilsener, the national beer of Ecuador...

“So who is this lady anyway,” I asked.
“The minister”
“Yeah, but I mean, who does she report to?”
“The President”
“Of what?”
“Ecuador”
“Oh, so she’s like the Surgeon General of your country?”
“Yeah,” they laughed. Then with glasses raised: “Here’s to the Minister of Health, the Surgeon General of our country” – and they drank. It was a good night.

Exorcism?

6-22-08 – Esmeraldas, Ecuador

Delfina Torres de Concha Hospital is the only public (free) hospital in a city of a couple hundred thousand. Fortunately (or unfortunately, depending on your take) it borders the roughest neighborhood in town, which translates into a lot of drugs (yesterday: a 1-year old in a cocaine haze) and violence (last week: a couple walking along the shore at 4:30 in the afternoon - she was raped first, he second). Although it might not seem to be an obvious connection, the hospital works closely with the police, who bring in a good share of patient flow. They tell me it’s best to have money when you’re robbed, because then you just get beat down; it’s worse not to have anything, because you’re killed for the inconvenience. They were speaking from experience.

But naturally, the longer I work, the more people I get to know, which is filling itself in as a small security buffer. For example, last week I was in the streets walking along when a bus passed by. Through an open window, a dude started whistling at me. “Jack ass,” I thought, and kept walking. But the dude got off at the next stop and accosted me. His profile fit that of the stereotypical college football defensive lineman, and I was scared. What did he want? I didn’t have money in my pocket. It turned out he just wanted to say hi; last week someone slashed his shoulder with a machete, just lateral to where the shoulder meets up with the neck. I helped sew his trapezius together and put a drain in his back to give the leakage a way out. His street clothes through me for a loop – that’s all. He was a pleasant chap.

Last week in a hole-in-the-wall joint behind the hospital overlooking the ghetto I saw a different healing – a procedure on the soul, performed in a church with plastic chairs, cement floors and not much else. When I got there, the clergy was praying up front and everyone else, numbering about 20, were on their knees doing their own thing – so I too sat down and started praying, not really sure what was happening. But then the church dude, with the front doors wide open, started praying against the drug addicts, crooks, thieves, prostitutes and children of the devil – implication being those in the neighborhood just below who might catch a trail of his voice through the speakers pointing in their direction. And the church started to fill, people came in off the streets, and it got busy as a beehive.

Church dude started praying for individual people, putting two fingers on their chest and blasting them with energized words. Sometimes the people would spin – faster and faster and faster until they were out of control. And as if it was an every day thing to turn people into tipsy turveys, the regular attendees facilitated the spinning by pulling aside chairs to make room for the spinners, who bounced around between innocent people. One lady hit me a couple of times, so I moved to the wall and got low to the ground where it was safe. Some of the spinners screamed things until they passed out. Most of them were caught by the regular attendees, but one lady started spinning out of turn (there was a line of people waiting to get passed out, and she hadn’t yet been prayed for – she just started spinning on her own) – so there wasn’t anyone to catch her, and when she passed out – BAM – knocked her noggin on the hard floor. Another church dude raced over – I thought he was going to see if she was okay, but he just started praying for her – perhaps to make up for lost time.

By then, the guy up front had changed tactics and was now putting people into convulsions. Could this be real? But sure enough, person after person stood in front of him, got blasted with prayer and tweaked out on the floor - and then seemed to be healed, or at least stilled, like a spirit-suction device sucked out the bad living inside of them. Sometimes the guy up front wiped a special oil on the patients’ foreheads, other times he poured water on them – I couldn’t figure out when each was called for. He did use a lot of sound effects through the microphone, though – beat-boxed bullet sounds when he touched people, or swooshing noises for the pouring of the water bottle.

In the end I’m not sure what I saw – a hypnotist, a man of God, a hidden cultural phenomenon? – but by the service’s close the beehive was quiet, people were healed, and something had changed. Simply put, “the photographer knows what he has witnessed, but not what it means” - Louis Schillinger. "Blood and guts". New York Times book report 5/25/2008. http://www.nytimes.com/2008/05/25/books/review/Schillinger-t.html?scp=1&sq=blood%20and%20guts&st=cse

A smile through the grimaced night

6-22-08 – Esmeraldas, Ecuador

She is eleven and beautiful – not on the outside, but in her spirit. On the outside she’s a wreck: burned, scarred, and weak from a car accident three months ago; she has a colostomy bag hanging out of her abdomen - a portal to her guts, a container for her fluids. Something’s not right – obviously, because her insides are on the outside – but more obviously because she’s spiking a fever of 104, shaking, and not looking good. But she’s a fighter and a dancer, and she puts on her best smile, a grimace, when I ask her about regatone music. It’s her favorite. We made a deal that if she gets better, she has to teach me some moves so that we can dance together. I didn’t contribute directly to her health care, but I made her smile and her family laugh, and it helped us all get through the night.

Señor de los cielos,
Yo soy tu niña, la niña de tus ojos
Entonces tenga amor - tenga amor hacia a mi

Father of the skies,
I am your daughter, the daughter of your eyes
So have love - have love for me

Diabetic feet

6-21-08 – Esmeraldas, Ecuador

She is sixty-two years old with mismanaged diabetes and does not speak much. Perhaps this is just her personality, or perhaps she fears I might take her foot. I don’t know yet that I might take her foot because someone tied a ratty yellow tablecloth around the ulcer, and it still hides the wound. The doctor has not yet taken a look either – just a sniff. That’s why I’m alone with the woman up on the second floor in an isolated room where cleaning won’t contaminate the ER’s resources – but the ER’s resources are already unclean, so I don’t know why I’m up here.

“Como se llama, señora?” I ask, using the usted form to show respect. She tells me her name and I try to start a conversation that doesn’t go anywhere, mostly because my Spanish is only functional, not fluent, and therefore debilitating at 2 o’clock in the morning. When we unravel the rag, I see that it was just a placeholder for a quarter of the underside of her foot that was missing, eaten away by disease. The edges are black, and the inside a moist rotting gray that squishes when I press it with my finger. Fanned out at the crater’s base lies plantar aponeurosis, a covering of tendons - the strings that pull on toes. She walks on it without pain, but when she tells me this there is an upward inflection at the end of the sentence, a subconscious effort to convince me it is not as bad as it looks. But really this is worse; it means her nerves have festered away too, along with the padding of skin and fat. She walks, then, only on tendons and muscles, both of which naturally lack sensation.

I want to be a surgeon because I like working with my hands; the OR is challenging and fascinating, and I don’t mind the blood. But if I want to help this woman, I have to cut off all the dead tissue – and this is harder for me because I’m in a drab room and I’m holding her leg and I can see her face. And I can see when I reach for the scissors that she doesn’t want me to cut, so I tell her not to look, that it won’t hurt, and I cut until it bleeds – a sign that what’s left is alive.

This is the first I’ve written about chronic disease in the northwest corner of Ecuador, but not because it is rare. It exists, and it is everywhere. Diabetes is out of control. Apart from trauma, it is arguably the most common disease seen in the ER, and second on the street only to HIV/AIDS, which has already infected one out of every five persons in the city. I’ll admit my ignorance that before arriving at this hospital I thought of diabetes as being an illness that primarily affected the United States – and primarily the Midwest, where one finds some of the highest obesity rates in the world. But I’m much more aware of diabetes here than I am back home because the disease is more difficult to manage in the developing world. People cannot afford glucose monitors to check their blood sugar levels. Because of this, the disease progresses, and because it progresses, it finds itself in the ER in patients who are missing feet – or at least, last night, a quarter of a foot.

*First picture comes from "Color Atlas"

Boca a boca - mouth to mouth

6-18-08 – Esmeraldas, Ecuador

I was on my way to the cafeteria when two other med students zipped by, screaming over their shoulders “come on – emergency, 3rd floor”. So I raced up with them looking ridiculous: a cup in one hand, a spoon in the other. At 75, she picked an awful hospital to go breathless and without a pulse. We got to it right away. My friend was at the chest, so naturally she was on compressions. I was at the head – that’s the airway station: throat, mouth… rescue breaths. But there is shit nothing in the hospital – not a backboard in the ER, not a facemask on the floors – and I’m still too young and idealistic for my own good, so I put my face down and blew into her mouth; a well intended impulse to give her her life back. Big mistake. I don’t remember if I heard the gurgling before or after the spit-up hit my mouth – either way it was disgusting. We called it quits and I came to my senses, which was the worst part.

My colleagues gave me a hard time for giving breaths without a mask, and they were only half joking. There are too many diseases you don’t want to have regurgitated in your mouth – too much to leave to chance. I know this, but can’t stand seeing people suffer. Suddenly the thought of contracting tuberculosis made me nauseous. My mind churned through the worst possibilities and jacked my innards like a sledgehammer. I doubled over as if to vomit but nothing came out. Dry-heaving is worse than vomiting because it accomplishes nothing. So I spit out what I could and stuck my finger in my mouth for the rest. But nothing came up and I’m too sissy to stick my finger deeper. In the background people were laughing, and for three minutes I hated Ecuador.

I’m still learning to be concerned but not emotional, alert but not excited, and quick but not hasty – the foundation of basic trauma life support. Fortunately, as my pops always says, “Every mistake that doesn’t kill you teaches you something. When you stop learning, you’re dead.” Here’s what I learned: no mask, no breaths – and no excuses to the rule. That, or get to the chest before anyone else calls it.

*The charts at the nurses’ desk indicate the patient had no known communicable disease.

To a better world

6-18-08 – Esmeraldas, Ecuador

To a better world

A father, a son, a love undone
And two small steps to the larger’s one
Hit the ground in perfect beat
Hand in hand they walk the street

He wants the best for his own boy
And gives a gift that fills his joy
A milkshake of peach and selflessness,
A lesson in life on how to bless

The ones you love and the world around
With acts of kindness that are not found
In the wealth of poverty of hearts of men
Witnesses, though, may flicker again

And from that light comes a healing thrust
Toward openness and renewed trust
That giving will profit and kindness will soothe
A blossoming world to a greater truth

Maggots

6-14-2008 – Esmeraldas, Ecuador

*Don’t read this if gross stories make you uncomfortable.

The first patient yesterday came in with a head laceration he received laying bricks four days prior. But it wasn’t like any cut I’d seen before – it was enormous, like a puffball with an opening the size of my thumb. The edges looked more nibbled than cut. I looked closer. “Bring me the light”. Sure enough – maggots. Nice a plump, a family of about forty. The doctors called other doctors who whipped out their camera-phones to snap pictures. “Why didn’t you come in earlier?” I asked. “Oh, it didn’t bother me”.

People here generally do not understand basic health care – how or why to clean wounds. A number of cases like this got me thinking on the cultural aspect of health care. Hygiene is very much a part of American culture – as is medicine to some extent. We know, for instance, to take ibuprofen for headaches or to put hydrogen peroxide on cuts. Take this intuition out of the equation and we’d become very sick very fast.

In vivo compressions

6-13-09 – Esmeraldas, Ecuador

It wouldn’t be a night out in Esmeraldas without a good gunshot wound. He came in around 11pm with a woodpecker’s nest through the side of his abdomen. Stuff like this is pre-approved for the OR, so off we went. A splash with the hands, a thwap of the gloves, a slice with the knife and we were in his belly – not looking good. His right kidney was like a kindergarten arts and crafts show but, again, that was the least of his problems. The most of his problems were shrapnel through a couple major vessels – namely the aorta and the vena cava. The trauma surgeon clamped off a few minor arteries but we were losing too much blood. Type O+. I’m type O+. I offered to drain a pint, but he needed more than that, so the case was on hold while the family ran to the blood bank on the other side of town. When his heart failed, we made a slice through the diaphragm and I put my hand up under his rib cage feeling for a organ bigger than a baseball, smaller than a softball, somewhere just to the left of midline. I found it and started squeezing. It was pretty amazing to see the monitor´s flat line pick back up again like a marionette. Eventually his heart took back over on its own right but only weakly, so I pressed it up against his rib cage with my right hand. With my left I counted down five intercostal spaces and inserted a needle between two ribs. As the plunger plunged, a drug called Atropine blocked the muscle’s parasympathetic nerve signals. In other words, it removed the heart’s brakes and the system sped up. The contractions got harder and harder but we were racing against time because he was still losing blood. In the end there was nothing we could do and he died on the table. On the way out of the OR I pictured the proud face on the other side of the trigger – some gang-banger a few blocks away, resting well, smirking. We are so awful to each other.

That was actually the third death of the night. The first two came in near simultaneously. We were trying to resuscitate a 73-year old diabetic woman when a young father barged through the doors cradling his four-year old and doing mouth to mouth. “Over there,” I yelled, pointing to the next table. I jumped over and he set the body down. The job is theoretically easy – airway, breathing, circulation, defibrillator – and in that order: the ABCD’s of life. I cocked his head back to extend his throat and open up his airway, but his jaw wouldn’t budge. That should have been a clue but I was not thinking straight. So I covered his mouth and blew into his nostrils – his chest went up and down with each breath but his body was cold, his arms rigid and, in case you have not figured it out, his clenched jaw was rigor mortis (when a body dies it stops making ATP, the gasoline of muscles – cut the gas and the muscles fibers can’t slide past each other, hence the stiffness). He had died on the way there.

I jumped back over to the first woman, now intubated, and took over on compressions. One and two and three and four… my orders were to count to 150 then listen for a heart beat – the ‘C’ in ABCD. But there was no ‘C’ and we had no ‘D’, and after a few rounds the doctor called the time of death at twenty-nine past the hour.


Around 4a we had the big morbidity and mortality talk, but I could hardly keep my eyes open. Over the previous few days I had written up a few thoughts, which I read, setting the stage for open communication. The front end was doctor-dominated - but in the end everyone contributed. Somebody commented that because we lack services, staff and speed, there really is not an Emergency Room – just a place to take cuts, burns and non-breathers in the middle of the night; I couldn’t disagree. We decided to make a few rearrangements – where to store tanks, how to give and receive orders - but time will be the test as to the effectiveness of our communication. After the others went to bed, Safadi threw on an episode of ER, subtitles in Spanish of course. He loves the series - mostly because it shows teams working together.

The rest of the cases that evening were pretty straight forward – mostly a lot of suturing. One guy came in with neck lacerations to his neck from a broken beer bottle. I was standing there getting ready to put in stitches when he pulled out a small piece of paper, opened it up and took a snort. “Are you insane?” I thought – but I couldn’t say anything because I was along in the room, didn’t know what the substance was, and didn’t want to get jumped.

Another patient came in helpless and ataxic (dizzy and staggering). “Take off your pants.” He took them off. “And your shirt”. It went too. “Now go sit in the shower for ten minutes”. He did. He did everything the doctor asked him to do – and would have easily given us his watch and cell phone had those not already been taken. Somebody gave him Escopalamina – a powdery street drug that affects one’s voluntary actions. It is used, of course, to rob people. The treatment involves exactly what I described, taking off the clothes and bathing – removing any residue and its lingering effects. You know the treatment worked when the patient realizes they are in a public shower in the skivvies and they don’t want to be. Genius… and hilarious.

I finished out the shift in the dining hall – shrimp empanadas for breakfast. I like the dining hall in part because I like eating, in other part because the people there are lovely. I like lovely people at the end of long nights.

-BH-

A long night

6-9-08 – Esmeraldas, Ecuador

Right now I’m lying in bed. The computer is in my lap and I’ve just been watching the cursor blink on and off on an empty screen because I don’t know where to begin. Usually I start with ‘yesterday’, don’t I? As in ‘yesterday I worked x hours at the hospital’. Yesterday I worked x hours at the hospital – doesn’t matter how many, but it was a lot… more than a day, and without sleep – we were slammed. There was a dude whose face was split in two, and the girl whose deltoid I pieced back together. They were both combative and noncompliant. The girl I had to wrestle to the floor so she wouldn’t hurt another patient who, coincidently, slashed her with a glass bottle. The guy… lot of blood, lot of anger – it doesn’t really matter. The point is I was already frazzled when the taxi pulled up; they slung a limp body onto a gurney and something ominous quickly permeated its sick self through the emergency room – the way the air feels before a tornado comes through.

As the story turned out, he’d been given an ampiciline injection earlier that day in his community hospital two hours outside Esmeraldas. Not a big deal – just an injection, so he went home to do whatever 14 year-olds do on Sunday afternoons. Shortly thereafter he went into respiratory distress and, presumably, anaphylactic shock. I imagine it got worse and worse to the point where he passed out – at least that’s when I first saw him… unconscious on a gurney. The story, though, we didn’t get right away – all we knew was a kid in front of us who could barely breathe.

Safadi instinctively grabbed his keys, raced to his locker and came back with the ambu bag – a balloon with a mask used to force air into someone’s lungs. Fitting, wasn’t it, that the oxygen tank didn’t work and the back-up was misplaced. I took off looking for a tank that worked like a bat out of hell, pens falling out of my pocket, stethoscope off my shoulders, shouting for people to get out of the way. Finally got him some oxygen. Safadi slipped a tube down his trachea so air went straight to his lungs.

“Quick – blood pressure” I asked a nurse. 80/40 – half what it should be. I looked up at Safadi “We need to start an IV stat”. One of the easiest ways to raise the blood pressure is to dump juice into someone’s veins – while the circulatory system stays the same size, the volume of liquid (blood) increases, so the pressure rises. But it was a disaster – five people standing around watching as one tried to get the IV going. One of my biggest frustrations is that some of the staff lack medical intuition.

“The body’s cold, some one bring me a thermometer”. The lowest number on the scale read 35 degrees Celsius – his temp was less than that. Normal is 37. Shit. Quick, cover him. We need bags of warm IV fluid. What? Don’t have any? Okay – heat up some water and cover him with warm blankets? What? No blankets? Shit. Give me whatever you’ve got – we’ve got to get his temperature up.

Suction! What’s in his lungs? A lot of fluid. Okay, clear his lungs every three to five minutes – it doesn’t do us any good pumping air in and out if his alveoli are covered and gas cannot exchange at the cellular level. She agreed but 5 minutes later was nowhere to be found. By that time I was on the cart, my body on his body with a paper gown wrapped around both of us, trying to give him whatever heat I could.

His BP rose steadily, although at the time it didn’t seem quick enough. There was a sigh of relief, though, when the cuff read 130/80. The decision was made to move him from the ER closer to the operating room where the heart monitor is located. They wheeled us down the hall – I’m still covering him, my elbows straddling his neck, propping me up, keeping the pressure off his airway. His mother was a mess, understandably.

The oxygen tanks in this hospital aren’t like the little portable green ones we have in the States. They are huge, like missiles, and they weigh a ton – you have to wheel them around on dollies, which is probably why the oxygen tank didn’t make the trip with us down the hall. Unfortunately the O2 tanks in the room outside the OR were malfunctioned and the patient went a couple of minutes (more than 10) without anything. As a reference, brain tissue starts dying after 5 minutes without oxygen. We finally got him on the monitor and his heart was all over the place – sometimes down at 70 beats per minute, but shooting up to 208 and holding steady. When his heart does this we press his eyes or massage the carotids in his neck, which stimulates a parasympathetic response that slows his heart back down so that it has enough time to fill with blood. Complicating matters, the pulse oximeter showed less than 25% of his red blood cells were carrying oxygen – as compared with 99% that you and I have at room air. Basically his body was not being fed. And so it was a constant game between ventilating and suctioning – the liquid in his lungs had to come out, but every second spent suctioning, not oxygenating, was costly. So we suctioned and his oxygen saturation plummeted – we ventilated and his lungs filled with liquid.

When I asked a nurse to squeeze the Ambu bag and breath for the kid, she told me that it was a man’s job - then left to catch some sleep (really, she was out in the hall on a gurney sleeping). Shit. Why? Aghh. So a few of us took turns bagging the Ambu for 4 hours. In the actual operating room was a machine that could do all the work automatically, but the director of the hospital wouldn’t give permission to use it. “Someone get me a knife,” I sarcastically ordered, “we’ll give him a little cut on the back of his leg then have reason to use the OR.” After a few hours we stole a portable ventilator from the Pediatric floor. It wasn’t being used, but the political levies broke in the morning because it wasn’t our equipment. Safadi and I were calling the shots, but I let him take the heat on this one – because technically I’m only supposed to be observing. He asked the question I wanted to pose – what else were we supposed to do? The hospital director’s response: we should have told the mother we didn’t have the equipment to take care of her son and left it at that. My spine froze.

We did everything we could but it became hopeless – he was most likely brain dead, although we did not have EEG confirmation. The family was also economically disadvantaged and could not afford keeping him alive even if we had got him stable. “Do we continue or do we stop?” asked Safadi. We stop. The decision was unanimous. So we gave him oxygen but stopped the Ambu.

Two others were with me when his heart stopped beating. I glanced at the monitor. That’s what a flat line looks like, huh? Then I sighed. Pobre cito. Little one, it wasn’t your fault and the world is not fair. Your mom does not know that you’ve gone yet. Let me take these tubes out of your mouth, these lines out of your veins, the death out of your face. Close your lips for me. Close your eyes; let me tape them shut and wash your body so your skin can catch your mother’s tears. Let me do this for you.

I wheeled him out and accompanied his family to the morgue – a dirt floor under the rafters of the hospital. They asked for the death certificate but nobody moved - a combination of fatigue and distress. I felt strongly that it was their right to have this done quickly. Somehow, then, it was on my shoulders to get the papers and explain them to his mother. It’s not a job I woke up wanting to do, filling that void, but it was important and eased her grief. She broke down in my arms and wept - and I hugged her and told her I was sorry, and I held her for a while and did not know how she would respond. But then she thanked me, and I melted, the tension in my body dripped away and I didn’t care about anything else – just that she knew we did everything we could – we who stuck it out.

But the everything that we did was not the best that we could do. We can do better. I know we can. Nurses vanished, directors twiddled their thumbs, and even some of the doctors shied away. In Esmeraldas this is just a job, a salary, a way to pay the bills, and sadly there is a disconnect between the responsibility that is called for and the heart that is needed. But not everyone embodies this mentality. There are a handful who care, who feel - who want to become better. Although it is counter-cultural, I’ve called a Morbidity and Mortality meeting for this handful to discuss the case, not as a blame game but as a means of learning from our experience - what went right, what went wrong, what we learned, and what we’ll change. I’ll let you know how it goes.

-BH-

Babies

6-5-08 – Esmeraldas, Ecuador

This morning I clocked out after 24.5 hours at Delfina Torres Hospital. During the shift I saw patients with weak muscles, clogged lungs, dengue fever, kidney failure, liver failure, and heart attacks. There were also machete-slit wrists, burns, broken bones, bullets – and to balance it all, both a baby brought into the world and a baby taken out. These heavy things I’m getting used to, and as the shock-value wears off, I shift from debilitating empathy to levelheadedness. I’m not sure if this is good or bad. Of course nobody wants to lose their sensitivity, but having inner peace and clarity of thought in the middle of craziness is kind of nice. Some might argue that the two are not opposed – that gaining in one does not come at the expense of losing the other. It sounds good to me in theory, but boy I’m telling you things are moving too quickly for me to make sure that the change understands the flexibility that it has. Or perhaps its not that I’m losing empathy, because I still feel for patients – but rather that I’m developing control over how that empathy gets expressed.

The saddest case, obviously, was the three-month old boy with head trauma who could not breath… at all. Right off bat I’ll tell you that he didn’t make it. The mother said she took him to see an acupuncturist whose needles instigated the problems. Whatever the cause, he had a cerebral hemorrhage that was steadily increasing the pressure in his skull. A CT scan, a Neonatal Intensive Care Unit, and a neurosurgeon would have been useful, but the hospital does not have any of these. We put him on a counter next to the sink and ventilated him manually for two hours. My only job was to watch his chest rise and fall every time I squeezed the bag. I was still watching his chest when he died - the post-mortem gasping from muscle spasms gave me a great false hope that a miracle was in progress. But it wasn’t. In the end we handed his little body over to his grandmother because his mother had already gone home.

Speaking of mothers who went home, the HIV+ mother that I mentioned a few days ago snuck her baby out without permission. The kid was not ready to be discharged, the mother was not educated and the situation is now a mess - the hospital has to send someone to go find her because she does not have his medication or his formula.

And one more baby story. As it seems to always be the case, I was temporarily left alone to take care of a room by myself – this time it was OB-GYN consultation. There was one mother on a table, big belly, waiting to give birth but nothing was happening. Another came in with a much smaller tummy – she said she was ready. I apparently missed the urgency in her voice. A bunch of things happened really fast, and before I knew it the janitor and I were hauling ass down the corridors to the birthing room. All he had to do was push the gurney – I was pulling, back-pedaling, steering and opening all the doors. Bear in mind I didn’t know where I was going. We kept telling her not to push even though the baby’s head was already out, and he kept telling me which way to turn. We got there alright, but there was no time to move her into stirrups - the baby was born on the gurney. After catching my breath, I walked out of the birthing room and into the waiting room, which is kind of like a runway for expecting mothers – half a dozen heads poked up, hoping I was not coming for their deliveries.

Normally in the early morning hours when the ER quiets down, doctors retire to their bedrooms and the others wipe off gurneys to catch some sleep. Last night, though, around three in the morning Safadi brought out a ghetto dry-erase board, gathered everyone around, and started teaching about the American Heart Association’s BLS protocol. He is a fascinating individual – young and suave with soft brown eyes and stylish black hair that is gelled in the front – the kind of guy who would have been homecoming king and valedictorian with a full-ride to Michigan. He’s a bit of a schmoozer, but he wants good things - like education, for example. Continuing Ed is not mandatory in Ecuador to maintain a medical license, and it is not subsidized either – but he is putting out half a month’s pay at the end of June to take an Advanced Trauma Life Support class – and when he comes back, he will teach the staff who are interested. I like working with him because he is a good teacher – he uses me to get information from patients, then asks my opinion. At the end he puts it all together so that I understand how to think when I see different combinations of symptoms. Outside of work, he also helped me find a cheaper place to live.

The new place is in the heart of the city, so I can’t leave after dusk – but I’m usually either tired enough to go to bed early, or I stay up reading, reviewing notes, and committing Spanish phrases to memory. Sounds lame, but I kind of like it – the time to think, be quiet, and rest. The room is small, but it’s got everything I need – a bed, a fan, a bathroom and a hook on a wall to hang some clothes. I buy water in 5-Liter bottles, powdered milk and snack on granola I brought from home – won’t last forever, but for now it’s nice. And the day before yesterday I bought a brush and some soap, so now I scrub down my hospital pants in the shower, then hang them up to dry over night.

Before the month is up I hope to take more pictures, but it is not easy or safe to do. It is not safe because the streets are dangerous. I’m told the kids are smart and know how to use razors to slice through pockets or cut straps off shoulders. The older ones just pull knives. Of course not everyone is like this, but it happens enough that even the Ecuadorians at the hospital take taxis at night if they have to go six blocks. There is no safe place to keep personal belongings in the hospital either. Theft by both patients and staff is so common that the Emergency Department’s only basic life support kit is stored in a lock box, and there is only one key and it stays with the doctor. Blood pressure cuffs also have a tendency to walk away and be sold outside to medical supply stores – which is why there is only two in the ER. And not to beat a dead horse, but we have to bring our own cups and silverware to eat in the cafeteria; during the day I hide mine in a crooked wooden cabinet in the back of the Minor Surgery room – I only take it out when no one is looking. Sounds paranoid, but that is the way it is.

Take care,
-BH-

Minor Surg

6-1-08 – Esmeraldas, Ecuador

Yesterday I spent 18 hours on an overnight shift in the Minor Surgery ward, a dingy room with pale green walls and five beds in the back of the ER. It is stocked only with latex gloves, disinfectant rinse and lidocaine. Everything else, including needles and nylon, gets written on a piece of paper for the patient to get. I collapsed when I got home. After three or four hours of sleep I tried getting up but nothing in my body wanted to move. Finally my legs mustered up the energy to throw themselves outside, so we went for a short walk. Sunday afternoons on the beach are lovely – everyone is out playing, eating ice cream, and dancing - families are together.

But families must not be together on Saturday nights when patients come in with shotgun blasts. She had 29 bullets riddled through her abdomen. The “doctors” (there were no doctors in the ER, only residents) were all busy sewing faces back together, so I helped a nurse cut off the woman’s clothing and prep her body for the OR. The radiograph looked like a Jackson Pollock piece, and unfortunately one drop landed between two vertebrae. Triage worked against her favor, as the surgeon chose to take other cases ahead of hers. She spent the rest of the night in observation.

Health care is free in Ecuador’s public hospitals is free but it’s not always great. Earlier in the day I excused myself to clear my head and stretch my legs. Before I’d taken 10 steps a woman started pleading for assistance. She didn’t care if I was only a student, the family wanted me to look at her sister’s body – then she started crying and I had no choice. We went up three floors and around a corner to an abandoned hallway, jammed open a stubborn door and entered the room. I went in first, not knowing what to expect. There in the front corner of the room was her heavy-set sister, lying naked in bed, half covered by a foul-smelling sheet - a colostomy bag dangled out her abdomen, and her nipples were taped to protect her modesty. A handful of people stood around her and a church-man was praying for a miracle. They asked me to clean her vagina with disinfectant because they thought it was the source of the putrid discharge. They asked also that I wipe her bottom. As gently as possible they tried turning her over but she shrieked. An 8-inch open incision in her right buttocks showed itself when they moved her body – it was a couple of inches deep. From it came the awful smell. Her arm was also broken, deformed and in a sling, but that was the least of her problems.

Little by little I pieced together the story. A car accident, hit and run. Taken to a hospital the family couldn’t afford. The colostomy bag was put in. Later a secondary incision in her buttocks made to relieve some sort of drainage. She was then transferred to the public hospital but abandoned at shift change when a resident forgot to relay the news that someone was up on the third floor in the back wing in an otherwise empty room. She needs a lot of help – radiographs at the very least to confirm a fractured pelvis (which I should have thought about before the family turned her over), in which case, if she’s still alive, she’ll have to make the 8-hour trip to Quito. I ran down and grabbed the resident I had been working with. We cleaned her body and gave her new sheets, then explained to the family what was written in her medical chart. But there was nothing more we could do - she needed specialists, and they will not be in for a few days. This is the sort of free care that isn’t always great.

Last night I also learned how to put in sutures. I had done this once or twice on a cow’s tongue in medical school, but this was my first time on a real body. One of the residents coached me through all the steps on my first patient. For the second I was on my own. It was a steep learning curve.

At some point a kid my age was brought in unconscious – big gash in the top of his head. I was the only one at the table when he came to. He wanted to know if he was going to die. Obviously I told him he wasn’t - and he really was fine – but my gosh… I didn’t think I’d be needing to know this kind of Spanish so early in the summer. When his family came back with the medical supplies, the residents wanted me to sew his scalp. I declined, though – there was an artery squirting blood and they hadn’t taught me how to deal with that yet.

There are other stories about faces being knifed, but I don’t want to tell gruesome stories just because they are gruesome. Here is a funny one, though. Well, I guess it’s not that funny, but you can imagine how awkward I felt. I can’t remember where the residents went or why I was left by myself to man the minor surg wing - but at one point there I was, alone, when in came 4 cops and an inmate from the penitentiary who had been puking blood. No joke, the oldest police officer took me aside to explain that the man was dangerous. They brought an x-ray along, so I threw it up and took a glance as if I knew what I was looking for. But this one didn’t have big arrows with questions like, “what is this structure?” written on it the way they did in anatomy lab exams back home – so after confirming with myself that I was at a total loss, I went and found the others.

Another guy came in bloody as hell from a motor vehicle accident. We cleaned his face up, but he declined shots because he was afraid of needles. I’m not sure how common this is, but the doctors didn’t seem to mind. In the States they’d have convinced him into receiving medication, because without it he runs a risk of becoming seriously ill. At the very least, it’s a small window into a sub-population’s attitude toward Western medicine.

Anyway, I should go find dinner.
Take care,
-BH-