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-