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