JKB meets Ecuador: 2010

Monday, November 15, 2010

Hospital del IESS

At Hospital IESS I worked with OB-GYN Dr. Salazar. Although I only shadowed for 3 days, I saw a ton that interested me. I made a point to arrive early on my first day because the hospital is ENORMOUS. Very easy to get lost. I definitely got great practice asking for directions, in spanish, inside this maze of a hospital. The ironic thing about that is whenever I´m wearing my white lab coat in a clinic or hospital, passersby think I have all the answers so people are constantly asking ME for directions! I always explain that I am a student, and just as lost as them. This always ends in a good laugh.
Day 1* 11/10: Cryo/Colpo Procedures
I found the Cryo/Colpo procedure room with 15 minutes to spare. A girl my age was waiting patiently outside for Dr. Salazar with questions about the need for a 2nd Colpo. She explained to me that didn´t feel that the first Colpo had been warranted, and now she had an appt for a 2nd with the same doctor as before (Her first doc was not Salazar.) She and I had a good chat about health, life, working at National Parks in the U.S. I definitely imagined her to be someone I could be great friends with. But we parted ways and I never saw her again.
Dr. Salazar´s visits that day consisted of 3 procedures: the most interesting was a Cervical Cone procedure performed on a young woman who had malignant cell build-up on her cervix. Evidently her first Cx Cone procedure had not been successful, therefore over time causing her cervix to build up a significant amount of cancerous tissue. Dr. S numbed her cervix with Lidocaine (2%?) and began the cauterizing the malignant cervical tissue. After cauterizing he used a tool that looked like a vegetable peeler to scrape away/remove it from her cervix. Yikes. The pt could feel everything! He had to numb her up 2 more times before it was completely effective. She also bled profusely and he had to cauterize and gauze her cervix for 30 minutes until it subsided. I asked him about this reaction to the procedure and he explainedthat there was additional pain and excessive bleeding because of the trauma caused by her first cone. The final product removed from her cervix was golf-ball sized tissue that he saved to send to pathology. We brought a wheelcahir for the patient to leave in and recover in a private room. Dr. S followed up with her 45 minutes later, checked her cx bleeding, her condition had greatly improved.
Day 2* 11/11: Consulations with Dr. S, Dra. Paez and Marco (resident.)
Dr. Salazar saw femal pts in 15-min appts for: APEs, mgmt of high-risk pregnancies, prenatal care and referrals for surgery. It was a slow day; we had a few no-shows. I learned a lot of gynecological vocab and talked with Dr. S et al about music, dancing, pop culture. I learned that Dr. S loves Cat Stevens, Barbara Streisand, and that his favorite song in all the world is "Dust in the Wind" by Kansas. His cell phone ringtone is an instrumental electric piano version of that song; when his cell-phone rang in surgery the next day it took everything I had not to laugh out loud!!!!

Day 3* 11/12: Laparoscopic Surgery: Total Hysterectomy for 47 y/o woman with uterine miomatosis
I arrived early to meet Marco, the current resident working with Salazar. Marco showed me the ropes about how to scrub-in, where to get booties and bouffants etc. We entered a pristine surgery room with 3 crash carts full of sterile pack-wraps containing a range of instruments and sterile scrubs for the operating staff to wear.. Each sterile pack had a perfect envelope-fold that I appreciated and I knew my old Lab Supervisor Patti would rate as A+! (Shout-out to Patti McKie @ SRPP who taught me all I know about sterile technique.) They used state-of-the-art equipment and had 6 different monitors displaying the hysterectomy. I wasn`t able to snap many great pics because the room had green lighting for most of the procedure. The surgeon used a pedal to control the cauterizing and cutting of the uterus. There were 4 incisions (points of entry) on the patients´ belly to allow a pathway for the instruments that would cut and cauterize internally. ......Fascinating.

To do the work of a surgeon you must apply so many forms of knowledge, skill and kinetic technique. As a team of docs, nurses, & residents you must work as a team to achieve the desired result. This was by far the most calm & collected team of medics I have seen conduct surgery. After the uterus was cut away laparoscopically, the uterus was removed from the vaginal canal with several instruments. Marco was excited because he got to assist in the removal of the uterus. The uterus came out with ease and was immediately placed in a plastic bag for future biohazard use? no sé. It was the size of an oblong football because of the uterine miotoma. The docs inserted a thick mesh to support her internal remains and avoid a prolapse. The patient awoke from anesthesia in a panic, as I would imagine. The docs were very good with her and used the phrase "sea tranquila" to calm her down and return to a stable state.

Saturday, November 13, 2010

Mindo, Ecuador

830 am, we´re the first passengers of the day

Kelly and I sporting our gear--- thick gloves are necessary to brake on the cable for the fast zip lines

my first trip across, I needed moral support from our guide

tarzan through the trees

Gabriel, our awesome guide

Here I am doing my best to stall our guide before we take last & furthest zipline

Kelly + JKB = Team Spirit

Chris and I riding the Tarabita to the waterfalls. This was, by far, more terrifying than the zip lines because it was an open-caged rickety gondola.

Attention Fast Cable (oh, but could they mention how HIGH UP it was? yikes!)

At the end of the Quiteños´ 5-day vacation week (10/30-11/3) I decided that it was the perfect time for me to leave town and travel. We left on a Friday afternoon and as I had hoped, the roads were clear, the air was fresh and the hostels were vacant. I traveled with CFHIers Kelly and 2 Chris´s to Mindo, Ecuador which is 2 1/2 west of Quito. It is set in the heart of a temperate rainforest and neighbors 2 rivers. To make an understatement, it is absolutely stunning. I found it ideal because I had been wanting a break from the city pace and smog for quite some time leading up to this excursion. Upon arrival we stumbled upon Hostel Armonia and la dueña (owner) Alicia showed us cabin accomodations entwined in tropical plants and an orchid garden; we were sold! In Mindo one of the main attractions are hundreds of rare bird species. I spied a toucan during my first breakfast at the hostel!

Saturday was packed with thrill-seeking activity & pure indulgence. We began early on Saturday, beating the rush to a local canopy company. The modest price of $12 included 13 ziplines of varying length (long ones were 300-400 meters) at nauseating heights. We had 2 guides to help me through my sweaty palms and moments of terror; i was on the verge of bailing out, but somehow I followed through with it and had the time of my life. For those who don´t already know, I have terrible fear of heights so this was a huge leap of progress to battle my fear, and the 2nd act since arriving in Quito (the first being climbing to Rucu Pichincha to 15, 000 ft.)

my transportation: Prospero

our adorable guide explaining the life cycle to us

the owl butterfly hatches

the cocoons are hung in pairs, like earrings, until they hatch

At the end of our ziplining adventure we were picked up by a guide with 4 horses; one for each of us. We rode horses to a butterfly farm. The owner gave us a tour and showed us the life cycle of a butterfly, beginning with the larvae and ending with a live hatch of an owl butterfly. She knows the timing of each species´hatch cycle so we lucked out to watch one hatch; the entire process took 2 minutes as the butterfly slowly tore out of paper-like layers and emerged from it´s cocoon with wrinkled wings. It was beautiful to watch the evolution of a winged creature. Afterwards I fed a butterfly ripe banana and watched in awe as hundreds of species flew around my head, occasionally landing on my sweater. We left on the horses and returned to town. Caught a taxi that drove us to a Tarabita--which is a like an open-caged gondola, another terrifyingly HIGH ride across a canyon---and the Tarabita dropped us off at trails that led to waterfalls. We stayed here for 1 hour or more, then returned to town for a tour of the chocolate factory. Kristen, our guide, showed us the chocolate making process from start to finish; it ended with samples! The cacao fruit doesn´t grow well in mindo so she and her boss have to travel to a farm one hour away from town to grow and harvest the cacao fruit; afterwards the fruit is brought to the factory and each fruit is deseeded, the seeds ferment for 2 weeks, dry, get transferred, get crushed in a machine, then get roasted and pulverized once again to create the cream of the cacao seed: 100% chocolate! her co. separates out the cocoa butter(naturally produced by the fruit) and then re-works it back into the chocolate for a creamy outcome. A certain proportion of sugar is added to make various grades of chocolate ideal for baking, or just eating. The brownie ice cream we had was TO DIE FOR! Absolutely terrific. For a refreshing break away from city life, I highly recommend Mindo.

Stage 1: fermentation then drying in troughs x 2weeks

the 2nd stage of drying the cacao beans

the kitchen where the magic happens

the pulverizer

ending the tour in style, by candlelight

final product! homemade brownies and ice cream

Monday, November 8, 2010

Carcalen Alto- Centro de Salud in North Quito

My experience at Carcalen Alto has been the most enriching thus far. This is true for me to due a variety of factors, including: the stellar staff with whom I interact--- Dra. Carmen Rengifo (my preceptor), Dra. Giacomo (the Radiologist) and the remainder of general clinic staff. All are very welcoming, open, and treat the patients like gold. Aside from this, I appreciate the range of services provided here at the health clinic (Pediatrics, ObGyn, General) and my final reason is that I really enjoy the community in which the health center is set. I´ve made some great connections inside and outside of the clinic. Carcalen Alto is located in northernmost Quito, it is funded by a trifecta of private and public sources (see photo below.) It has the feel of an Open Door Clinic, similar to what I know in Eureka, CA. Here´s a day-to-day look at the range of activities & observation I participated in at Carcalen.

Day 1: Outreach day. An tiny pre-assigned group of Doctors and assistants walk through the neighborhoods inquiring door-to-door about whether or not there are disbaled people in need of healthcare living in each house. Just as soon as I arrived to meet Dra Rengifo, we turned back around and left the clinic to embark on this outreach adventure. We began by ringing doorbells, hoofing it through gated communities, flagging down cars and passersby asking if anyone knows of mentally, physically, elderly, or persons disabled in such a way that they might need special assistance int he form of a doctor coming to their house to provide healthcare for them. At first I had no idea what was going on and had to ask the Dra. quite a few times where we were, what was our purpose, and then what to say (because she asked me to start ringing doorbells and intercoms.) I finally got the hang of it, and was rather embarassed at first because I didn´t feel confident that I could communictae my purpose. Then I realized that most everyone was very grateful for the inquiry, and had only compassionate words of declination if there wasn´t anyone in their household who needed services.

Day 2:
Today I observed "Prenatal visits" (in inglés), "Control" or "Carnet Prenatal" (in Español). On account of the Free Maternity law, women between the ages of 15-45? receive free prenatal care including ultrasounds and paps-
Dra. Rengifo has a flip-book from the 80´s with collaged pics of proper nutrition for the woman and her child, how to stay healthy after your pregnancy, how to avoid getting varicose veins....... all kinds of fun stuff. There is a program offered by HUGGIES that she enrolls pregnant patients in: 3 months of free diapers if they filled out said application. This day was super busy, a constant flow of interruptions, Dra. R keeps her cool and maintains a tone of respect and level of patience I can´t imagine having with such demand from staff, patients, and pharm reps.

The sign that greeted me every day when if got off the bus

the community-based mission and vision of Carcalen Alto

A great sign encouraging all pregnant women to get HIV tests

Dra. Carmen Rengifo y yo

The brigade funding for Carcalen Alto

DAY 3:
PAPS GALORE!They sell an affordable pap kit here for patients who fall in the private pay category: $2.50 for a kit which consists of: plastic spec, spatula and broom. I got to do 3 paps, my first and most difficult on a woman with no cervix (she´s had a hysterectomy.) The other 2 went well, successful, and I felt more comfortable after the 1st. one spec exam just to check for a girl´s IUD strings. one breast exam. I held lots of crying toddlers while their mothers were getting exams. I battled my own intolerance of free-range children when one patient´s curious child proceeded to pull all items within reach down/off the doctor´s desk. The next thing I know he´s sticking his head in the spec bucket----then playing with the sharps container-- the mom seemed unaffected. I ran to his rescue and saved him from a certain fate more than twice. A good lesson of patience for me?

Day 4: A celebration
La aniversidad del Centro Salud Carcelen Alto: 11 years of operating as a clinic. Club de Leones. Policia judicial and ministerio publico. A solemn gathering (it was referred to w/ this wording) of all staff at carcalen alto. president, ministeria de salud and many other top-shelf staff gave speeched. it sounds as if it has been a successful 11 years, patient load has grown in size esp between 2008-now.

Day 5: Carmen Rengifo fashioned me a Thank- you letter for the supplies i donated to C. Alto. She couldn´t spell my name without studying my name tag (so adorable) so eventually she borrowed it for a few hours to produce a correct and official letter. Today (Friday) I got to work with Dra. Giacomo the Radiology dra. She´s amazing! I saw several routine exams and identified so much anatomy. She´s a great teacher, efficient in each U/S exam and compassionate with patients. I aspire to be like the 2 Radiologists I´ve met thus far. They know how to rock out a U/S shift--6 pts per hour-- and do a damn good job. Also, not sure if it´s just a coincidence that the two docs working in my field of interest are the only two medical providers that successfully put up boundaries with their patients.

Wednesday, November 3, 2010

miscellaneous beauty (food, art, family, friends)

Long time......it is not written. Life moves fast here! It´s amazing how much I do in a day but can´t find the time to express in forms other than pictures. The past 2 weeks I´ve been on a tour of Quito.....exploring hidden gems tucked in the nooks/crannies of the city, indulging in customary "dia de muertos" food and drink, Rowdy busy futbol parties, and dancing on the Equator line 0º Long 0º Lat in Mitad Del Mundo (see pic below)

The middle of the world; CFHIers standing on the Equatorial divide

It's been a phase of mixed emotions. For the many connections I make daily, I am simultaneously saying good-byes. The October batch of CFHI students left and we are welcoming in the newcomers. The last weekend of October, Francia (my Chilean mamita) hosted 3 doctors/friends from Chile who attended a conference in Quito for 4 days. We had a blast! They were terrific houseguests and friends as they lived up dinner with their hilarious stories & I got to improve my Spanish through our conversations. Chileans speak 10x faster than Ecuadorians, and with a slightly different accent so it kept me on my toes. One night we all went out for drinks & dancing at a salsa club. I made a great connection with them; they felt like family, and they were kind as to offer me a place to stay in Chile when I visit in the future. Each day here in Quito is beautiful and overwhelming; from the bus rides to my breakthroughs in language/communication. It's invaluable and it keeps me sane, curious and connected.