Evaluation/Overview

8/20/2008
Ben Huntley
Esmeraldas, Ecuador
A loco hospital in the Latino hood

“Puedes coser?” That was the first question that came my way after the director at Delfina Torres de Concha provincial hospital introduced me to the ER staff on day number one. Coser, coser, coser… shit – what does that mean? I fumbled for the electronic dictionary in my pocket: to sew. They wanted to know if I could stitch wounds shut. “No, not really – but I’d like to learn”. This was just minutes after the director made it clear that for the next few months I was only to observe. So I observed as the first patient was put back together, listening carefully to step-by-step instructions on how to slip the needle through jagged lacerations… but from then on out I was on my own – sewing fingers and faces, tendons and toes, lips, tongues, and eyebrows - visible and un-visible parts of the human body, children and adults, whenever and wherever the need presented itself. And it didn’t stop there…

By the end of the summer I had delivered babies in taxis, on gurneys, through Caesarean, and in proper birthing rooms – I had pulled out babies and bullets, slapped together what machetes slashed apart, detoxed street drugs, rammed tubes through every human orifice, and even thrust my hand into a man’s belly, through his diaphragm and up under his rib cage to give direct cardiac massages in a last ditch attempt to save a life that was shot down and brought into the OR. To be frank, I was pretty much a doctor – mostly in the ER, mostly in trauma, but also in clinic, OB, paeds and other areas depending on the needs of patients and gaps in staffing. I hesitate writing that – I was pretty much a doctor – because it sounds so damn self-aggrandizing. But artificial humility has about as much worth as a hair on a bar of soap, and if I downplay these experiences then I am neither being honest to you nor to me – so instead I will just tell them.

Esmeraldas was not an ideal learning environment. Ideally I would have been at someone’s side the whole time, asking questions, learning – developing my understanding of medicine that way – the right way. And this is what I had hoped to find – but rarely do realities match expectations, and all the less so in the developing world. Instead, I arrived to discover an entirely different reality: a dirty hospital in shambles with two stethoscopes for an entire ER and probably an equal number of days each week when one or more doctors would fail to show up for only the Lord knows why. In Esmeraldas I performed above my training level, skill set, and comfort zone – I did procedures and wrote orders that I would never have been licensed to do or to write in the United States. And it was hard. All the time I questioned what I was doing, why I was there, whether or not this was right. In the end, though, I found a way to be at peace with myself and with the situation because the bottom line was that regardless of any technicality, if I did not perform, patients would wait for hours… or die. And so I did the best I could – sometimes putting in 100-hour weeks, all the time researching on the Internet what I did not know so that I had enough to carry me through the next day. Some of the time the research was trivial – like what is a swollen prepuce and how is it treated? By the time I figured that out, the patient was gone and I never saw another problematic penis again. Other times it was critical – like reading up on myasthenia gravis, only to spend the next 34 hours on the longest shift of my life with a patient in myasthenic crisis in the back of an ambulance, zigzagging at warp speed through the Andes to find a hospital that would receive her.

That is not to say I was without mentors – I had two: Dr. Nicasio Safadi and Dr. Christian Vargas, in clinic and surgery respectively, and they were great. Safadi was a natural teacher, and at around 3 each morning when the ER settled down, he’d pull out an old rickety dry-erase board and educate his peers on Glascow scales, syncope differentials or what to do in the case of true emergencies. Likewise Vargas spent an incredible amount of time with me in minor surgery and the OR. But more often than not, or at the very least a surprising amount of time, I was on my own. More than all the stories I walk away with, though - more than the experiences, the thrills, the crazy days – I have come away having gained a great deal of self-confidence, having understood that not knowing something does not mean I cannot know something, and that I should not wait around to be spoon-fed. This summer I learned to educate myself when educating myself meant something real – meant someone’s life, their discomfort, or their road to recovery.

I suppose after a page and a half of my gut feelings I should probably back track and lay down the premise of this crazy adventure – how and why I got there, and what I did on a day to day basis. In January of my M1 year I started flipping through pages of past student reports in the Global Programs office, hoping to find something that caught my eye. It was important for me to find a Spanish-speaking location because I figured of any language, with the rising Latino population in the US, brushing up on Spanish would prove to be most helpful in the years to come. A few papers interested me, but nothing really jumped out; I have done a lot of traveling and was looking for something less structured, not a cushy program that would take care of my needs. So I closed the books and jumped online to www.idealist.org - a website that lists tens of thousands of internships and volunteer opportunities worldwide. Filtering those down with keywords medicine, Spanish, etc – I finally stumbled across an organization whose mission statement I believed in: Yanapuma Foundation (www.yanapuma.org). Although they had not done much work in the healthcare field, they wanted to get involved using a model based on sustainable community development. Sounded cool, so I called. A few Skype interviews later and they had a place lined up for me to spend my summer months: Esmeraldas, Ecuador.

A couple things about Esmeraldas. It’s a big hot city (300,000 people) on the west coast, packed with more Afro-Ecuadorians than anywhere else in the country, and it is violent. Really violent. It is poor – really poor. And, like the rest of the country, it is strangled in racism. Yanapuma set me up with a safe, fancy hostel – but it was too nice, therefore isolating, and at $14/night was outside my budget. Within five days, however, Dr. Safadi helped me find another place in the heart of the central district called Hotel Chalet Real. Hotel meant my room came with a bed, a fan, a tv and a private bathroom. I rented by the month, $110, and shared the place with a few cockroaches. It was everything I needed, nothing I didn’t, and worked out just fine – about ten blocks from the hospital. Walking was not an option during the dark, however, as even Ecuadorians grabbed taxis (a buck a ride within the city – cheap insurance) to avoid getting jumped. It took me a while to figure out the hospital schedule, and for the first week I assigned myself day hours from 8-5 Monday through Friday, then a few hours on the weekend, which I had heard was crazier. But as it turned out, doctors in Esmeraldas’ ER worked “la guardia” (24 hours) every third day – and soon I jumped on with guardia numero uno, putting me with Safadi and Vargas. I was usually pretty tired after the 24 and would rest most of the next day, but then frequently popped back in during day hours on the other “off day” to lend a hand. Apart from a 10-day trek into the Amazon basin, splitting the time with a shaman/medicine man from the Secoya tribe and canoeing downstream with the Ministry of Public Health for a rabies vaccination campaign, Esmeraldas was it for the rest of the summer… just plugging away day in and day out.

I had studied Spanish in high school and taken a semester in college, but lost much of those abilities in the years since. Fortunately I pick up language quickly, though, and within a few weeks was running on my own two feet - interviewing patients, taking histories, talking with police, etc. After taking five days worth of classes in Quito, I moved over to Esmeraldas, but the first week there was rough. The Esmeraldeño accent is hard to pick up – they swallow their s’s and move their lips like a hummingbird’s wings. For a while I would just tune out Spanish in the OR that got blasted my way, clue into the Latin, read body language and get by that way. But the accent came with time and soon enough I was telling my own jokes, making people laugh, and had integrated myself into the team.

The trip ended up costing me more than I had anticipated. For one, I didn’t think that the Freeman Scholarship committee would award me money if I placed it at a high price, so I low balled my figures and told them I’d cover the rest. But even then I ended up spending more than my expectations. The ticket, on American Airlines, round trip from Cedar Rapids to Quito was about a grand. It was a few hundred to the Yanapuma foundation for office fees and private lessons, and three hundred for the apartment for the summer, but then between $10-$14/day for hostels when I was in Quito or on the road. Food at the hospital was free, which I ate whenever possible, but I also ate out. You wouldn’t think it would be so bad, but 60 cents for bread here, a buck thirty for some yogurt there, drop five for a plate of seafood, and by the end of the summer I was out a lot of money. The largest surprise cost, however, was communication – and it always is for me. Internet is only a dollar an hour (double that in some locations if you videoconference) and pre-paid cell phone cards always go fast – between 5 and 15 cents a minute depending on the cell phone company of the person you were calling… but like food, that goes fast too.

In the end, would I do it again? I don’t know know. I never felt safe in Ecuador – especially not in Esmeraldas, but I learned a lot. It’s not the place to be unless you’ve traveled on your own in sketchy places before, and definitely not unless you speak Spanish, because apart from an occasional “what your name is?” and a few feeble attempts at Whitney Houston’s “I will always love you”, no one spoke English.

If you’re interested in learning more about these experiences, they're all here. Start from the beginning and work your way back - and at the end, email me your thoughts: benhuntley02@hotmail.com

BH

In gratitude

This has been a long, fantastic summer of learning, which would not have been possible without the support of many people who deserve to be recognized. So with gratitude, I would like to thank the Freeman family for financially supporting this endeavor, Robin Paetzold of the University of Iowa College of Medicine's Global Programs office for her permitting me to take this leap, to my family and friends for checking in on my sanity from time to time, to doctors Christian Vargas and Nicasio Safadi for their patience and guidance both in and outside those hospital walls, to the Ecuadorian interns rotating through Delfina Torres who housed, fed and befriended me during these latter months, and lastly to the patients, whose names I have changed, and their families who have generously allowed their stories and photos to be shared.

El fin

8-1-08 – Esmeraldas, Ecuador

In two weeks I’ll return home to Iowa, the land of milk and honey – to green fields and rows of corn, where farmers wear overalls and strangers say hello. For the most part people will be courteous to each other, and intentional with how they spend their time. I will also be intentional with my time, hiding in the Kalona bakery until the Amish concept of peace washes dirty old Esmeraldas out of my bones.

The grit here brought a patient in last week who was unaware of a bullet in his leg. The story he told put 9 millimeters in his chest but a machete through his groin. Crouching down, however, to look at the bullet mark in his leg, I astutely declared “Sir, I think you have a bullet in your leg.” That it was even plausible to mistake a machete slash for a gunshot gives me the eebie jeebies.

But as any good NRA card-carrying member will tell you, guns are not always used for evil; this allows peacekeeping officers to both serve and protect. Except that last night for shits and giggles a police officer snuck out the back of the ER with a doctor to fire artillery over the roughest neighborhood in town. It was kind of like rousing up a bees’ nests or throwing smoke bombs in crowds of drunks – not the brightest idea.

Speaking of bright ideas, the pharmacist has a couple good ones. One of my favorites involves smoking cigarettes in the hospital regardless the patients in respiratory distress. He stays in his office, though. I’ve seen another walking down the hall with a cig dangling off her lips like she was in the garden of Eden and unashamed.

Racism also rears its ugly head on the coast. I have not yet talked about it because I don’t quite know what to say other than it is here and it is awful. One of the nurses of Chinese descent is called China. I asked someone once what her name was but they didn’t know. Two months ago a big black guy came in with his face split open from his forehead down through his nose from a motorcycle accident. He was in discomfort as he came to and understandably uncooperative. “Stop moving,” barked the surgeon, who was trying to suture shut the wound, but the patient continued wrestling about. “Negro, NO!” Thwap – and he hit the dude hard on the side of the head with a pair of pliers.

Another doctor just utters “f***ing n*ggers” when he wishes to express his distaste. Black people are violent, he says. But it didn’t take long for me to point out a few exceptions: Malcom X, Martin Luther King Jr, or any number of black doctors and nurses on our staff. So he adjusted his stance to say that from his experience, on the whole, black people are more prone to committing acts of violence. To this I contested, “But Doc, black people also make up a higher percentage of the population – their violence is in proportion with their numbers.” He disagreed. So partially out of my own curiosity, and certainly to prove him wrong, I secretly began tracking cases of violence by race, putting gunshots, stabbings and bottle slashings in separate categories. But now I don’t know what to do because in the last three weeks the only tally I have outside the black-aggressor column is from a mestizo man who shot himself in the shoulder. Hoping for a different spin on the obvious, I asked a black police officer if black people in Esmeraldas really were more violent than the others. He looked at me like I was stupid - of course they are more violent. He didn’t say why and I got pulled away before I could ask.

A few days later three black men in their early twenties were shot down one block from the hospital. In spite our best efforts, two of the three died minutes later in our ER. After a long operation, the third pulled it through – but in the middle of the case someone started snoring. I looked up from the table and in the corner of the room the anesthesiologist had fallen asleep cross legged, arms folded, sitting on the floor with his back to the wall – an intentional decision. There is no way to tell for sure, but I wondered whether he’d have fallen asleep if the patient was of any other race.

My hope was to have left this place better than when I found it, having encouraged my colleagues to also want improvements in their services and in themselves. Toward that goal, we have become noticeably more efficient as a team in response to trauma cases, and we have even developed a trauma kit so that in true emergencies we have the resources to be self-sufficient. And we are getting better. But the system needs more than a kit, and more than three months of effort. On an individual level, I know I have contributed good – delivering babies in the back of taxis, sewing tendons, closing faces, and racing all the time for oxygen – but the macro level remains a mystery. Whether or not bigger changes will last is beyond me, but at the very least I know I come away richer. These have been tough months, but through them I’ve gained confidence in myself, and that confidence I trust will carry me through the years to come. I have enjoyed my time here but am ready for home, ready for the next challenge. Thanks for reading, BH

Angél

7-26-08 – Esmeraldas, Ecuador

“Do you remember me?”

“No ma’am, I am sorry I do not.”

“I was here two months ago with my boy.”

Nothing clicked. Two months is a long time, filled with hundreds of patients – I cannot remember them all, let alone their families. I cannot remember their faces. A few of their stories, however, I will never forget.

“He was 12,” she said.

Yes. There it is. It exploded on that one tiny detail. Funny that should be the first clue she offered, because his age is burned into my mind. Yes, it would have been about two months ago that he lost his breath and turned cold.

I let my head drop as if words of confirmation were about to come out, but they couldn’t - so my head kept falling, slowly, coaxing the next bit to let itself be heard. The icebreaker. Either I hit the nail on the head, or I was absolutely wrong… but if I was right – if I was thinking of the right patient – then for his mother’s sake I had to ask the question before getting any more information. So it came out slowly…

“He… died that night,” I confirmed, double-checking my memory.

“Yes, that was my son.”

We knew each other in that moment, his mother and me.

She lost his death certificate and wanted another – and wanted it in my handwriting. It did not occur to me until right then that when we ask families to fill out the personal information, forever the death certificate has their handwriting staring back at them. Of course I’d fill out the rest of the pages for her. His name was Angél - I’ll never forget that name.