I´M IN ECUADOR!!!!!!! I`ve been here since April 2nd... and the time has been FLYING!!! Heading home on April 29th.. can`t believe that my 4 months abroad are just about over.
Let me give you an update on life as I know it... since my last post.
My last posted ended with me in Cusco, about to embark on a 2 day ´´Motorcycle Diaries´´ adventure with the one and only Harry Cavero. And an adventure it was!!! SO MUCH FUN!! We loaded up his motorcycle with a tent, sleeping bags, a change of clothes for each of us, and then I wore a backpack full of 2 days worth of food and a few other random supplies, and the two of us set off out of Cusco --him driving, me sitting behind-- on the road that leads to Lima (if you went that far you`d arrive like 20 hours later..) with the destination of the hot springs of Conocc in a beautiful valley next to a raging river. This was March 21st. Yes, so we got all loaded up and set off on the adventure, all pumped up and excited... and within 10 minutes we found ourselves in a terrential downpour of rain.. complete with thunder and lighting, and even little chunks of hail. Perfect weather for a motorcycle ride. For the 4 1/2 hour ride, about half of it was in the rain, coming from all directions Forrest Gump style... with me clutching Harry, scared to death the motorcycle was going to spin out on the wet roads and we`d plunge to our death off the side of the cliff... but no, we survived!!!! The ride was actually quite beautiful when the rain cleared and we could actually see ahead of us... once you leave Cusco, you get to an open plain that is just filled with fields of crops for as far as you can see. Very picturesque, especially because over the open plain there were areas of sunshine and areas of clouds with pouring rain, creating quite the dramatic landscape. As a break we decided to stop at some local Incan ruins that Harry had never been to. We got there and found them just to be old Incan terraces for cultivating crops, so not that impressive, but the cool thing was that the people of the town were actually using them to grow crops! -- and they were doing exactly what the Incas did a long time ago.. they were testing out different seeds in different growing conditions. Pretty sweet, I thought. Anyway, back on the road we continued and eventually climbed out of the plain and emerged at the top of a gorgeous and huge carved river valley. It was cloudy so there wasnt much of a view, but Harry says that on clear days you`re totally surrounded by snow-capped mountains, including the tallest mountain in Cusco-- would´ve been sweet, but we weren´t that lucky. From there we continued along the road at the top of the valley for a couple of hours, with occasional descents and climbs to and from the river below.. absolutely beautiful, especially at sunset which is when we were there. We also stopped at Incan ruins called Tarawasi -- or ´´House of Tara´´ -- which I naturally thought was awesome. It was a ceremonial site along an old Inca trail.. with intricate steps leading up to a ceremonial area containing lots of niches for Inca mummies. So, obviously, in order to fully immerse ourselves, Harry and I posed for pictures as mummies within the ruins.... and then continued on. The ride was long, and especially painful in the dark because I no longer had scenery to distract me from the scream of my buttcheeks on the rock hard and narrow back seat of the motorcycle. Fabulous. But we finally found the turnoff from the main road and embarked on a 20 minute steep descent to the river, as the thermal baths were located right next to the water. All fine and dandy until HARRY`S BRAKES WENT OUT AND WE STARTED FLYING DOWN THE CURVY BUMPY UNPAVED ROAD -- PLUNGING TO OUR DEATH!!!!!!!! SO SCARY! He eventually got us stopped, after dragging feet and using the front brakes. But that was it for me.. I bolted off that thing and refused to get on again and walked down the rest of the way. Not cool! We made it to the baths about 9pm, both of us exhausted from the ride but thrilled with the adventure...only to find the water, in the hottest pool, was about as warm as swimming pool water after a cold rain. :( We decided not to swim, and instead set up the tent and enjoyed the sound of the wildlife and the river before falling asleep. The following morning, we did take a plunge into the baths, though not for long. We then left and climbed to the very tiptop of the valley to a town to get breakfast and get the bike and brakes checked out. After we got the clear, we headed on our 4 hour drive back to Cusco. On our way back we stopped at more Inca ruins that were absolutely phenomenal.. once we got there. Unfortunately the actual task of getting there was a bit of a chore and we almost really hurt ourselves. The ruins themselves are a bit up a hill off the beaten path and there`s just a muddy walking path to get there. Well, we were both a little lazy so Harry decided we´d just ride the bike up the path. Big mistake... we skidded out like 5 times and got our legs trapped under the bike twice!!! And also lost control in the mud and came to a dead stop after smashing into a rock.. whoops! Don´t worry, I got it on camera because it was hilarious. And this is why we wear helmets. But anyway, when we finally got there it was beautiful, and I`m sure that if there were a bit closer to Cusco, there would be much much more tourism there. But lucky for us, there wasn`t! There were all sorts of terraces, with a couple areas for religious worship, and a beautiful river running through that the Incas had redirected in order to have it run by their areas for religious ceremonies, plus a huge natural rock on the side of the mountain with a cave which apparently was used for connections with the underworld. It gave me the heebie geebies so I didn´t go in, but it looked cool from the outside! And the afternoon was beautiful and sunny, and everything was covered in wildflowers. I totally fell in love with that place. The rest of the trip was uneventful except that it was awesome and thrilling to be on the motorcycle.. I totally felt like Che.
The next couple of days I spent working in the clinic in Ollantaytambo, which is a medium sized city in the Sacred Valley on the way to Machu Picchu. Overall, I´ll be blunt, it was a bad experience with more shadowing and very basic sore throats and coughs, so it wasn´t exactly what I was hoping for. The sweet thing, though, was the ruins in town. Harry came by on my last day there with his tour group, so I tagged along with them for the afternoon which was great. There are also some ruins on the massive mountain across the way from the main ruins...I spent one afternoon climbing them with Erik Anderson (a med school buddy), and two other gringos and that was a blast -- though it seriously gave me an appreciation for the hiking ability and lung capacity of the Incas back in the day. On Saturday March 6th I boarded a train and headed to Machu Picchu Town, aka Aguas Calientes. That night I met up with Harry after he finished his hike into Machu Picchu with his tour group, and the following day was spent at Machu Picchu!!!!!! It wasn´t my first time there, but regardless it really is an amazing place.. very spiritual and mysterious.. as well as totally impressive to see everything that the Incas built and learn all about their empire and studies of the natural world.. it is just fascinating. Unfortunately it was a pretty crappy morning.. rainy and cold.. so it wasn´t showing all of it´s splendor... but it was a nice way to end my time in Cusco.
That being said, the following day, Harry and I left Cusco and flew to Lima. We spent the day hanging out in Lima, eating ceviche, walking around, saw a movie (there are no theaters in all of Peru except in Lima!!!!), and then that night boarded an overnight bus for an 8-hour ride to the town and region of Huaráz. We spent the next 3 days there and totally had a blast. Huaráz is a cute little town nestled among big mountains in the Andes. It´s the best area of Peru to do some serious mountaineering, (I´m talking 16,000 to 18,000 feet summits!!!), which we obviously didn`t do.. but you can also take day trips through this valley between two massive mountain ranges and that´s what we ended up doing. The tours took us to multiple tourquoise blue mountain lakes where there was ample time for photos and a little bit of hiking. We also visited a town named Yungay that was absolutely crushed by an earthquake and avalanche in 1970... 26,000 people died. Can you imagine? What`s the death count in Japan right now? 14,000? The town itself is actually buried beneath more than 10 feet of earth and just walking around and thinking of all the people who died beneath your feet 40 years ago was a pretty humbling experience. We also visited the ruins of Chavín which Harry really wanted to see (I was pretty ruined-out).. but it was kind of interesting to see the homestead of a pre-Inca culture. They had this temple that had crazy maze-like walkways underneath and a massive pole that was a religious icon.. the place freaked me out so I didn´t stay long underground... but it was nice to visit. On March 31st we took an overnight bus back to Lima and spent our last day together on April 1st. We basically just ate ceviche and drank beers all day next to the ocean. It was awesome and a nice way to conclude our weeks together. The following morning we parted ways, as Harry headed back to Cusco to work, and I pressed on to Ecuador to complete my final 4 weeks of my 4 month trip.
Arriving to Ecuador on April 2nd I was supposed to meet up with my friend Johnny in Quito -- a friend from my first Ecuador trip 5 years ago when I was in college.. he now lives in a town in western Ecuador -- but he got delayed, so I instead spent the day hanging out in Quito. The highlight was really really really good Mexican food (I had been craving it for about 3 months)...but that´s about it because I had done the touristy stuff of the city when I was there before and didn´t want to embark on a whole day adventure again. The following day (Sunday April 3rd), I boarded a bus and headed to Pedro Vicente Maldonado (aka PVM or Pedro). Pedro is the town where I´d be working for the next month.. it´s about a 3 hour ride from the mountains of Quito to the subtropical area of PVM and has a hospital started by a Notre Dame grad that basically is everything that I, in theory, stand for in international health. It´s freaking awesome. Learn more about it from their website... www.andeanhealth.org --> I refer you to the link on the left side under ´´Impact´´ that says Hospital PVM. That´s where I´m working. The organization (Andean Health and Development) just started the process of building another hospital in a town two hours away called Santo Domingo. Basically, this organization is singlehandedly changing the way health care is delivered in Ecuador... and it´s totally awesome. So I´m here for a month to learn -- they have 7 family medicine residents that rotate for Q4 call and have their own clinics and also cover the emergency room. It´s pretty phenomenal what they´re able to accomplish here in rural Ecuador with so few resources.. and though it´s not perfect (I´ll tell you some stories in a little bit), it´s much much MUCH better than what they had before --- which is basically nothing. Before HPVM the only option for about 30,000 people in the northwest region of Ecuador was to go to overcrowded and expensive hospitals in Quito (a 4-5+ hour ride away.. obviously not good for any emergency!!) that focus mostly on specialty care and don´t really offer preventive or primary care... or to go to Ministry of Health clinics or hospitals spread out over the country, that nearly always are understaffed, undersupplied and basically unreliable. So, this place in Pedro is great for the community because they deliver unparalleled, reliable care.. and it is (mostly) affordable -- I could go on a whole rant about the payment system here, but in order to keep this blog shorter than a massive novel I´ll hold off for now. But, it´s pretty interesting... maybe next blog I´ll expand. They´ve been here about 10 years I think and have done such amazing work as a private hospital that the government of Ecuador has taken note and is starting to implement the Andean Health model into the country´s system. Talk about great public health policy!!!!
My first day was April 5th and they´ve been working me pretty hard ever since (which I don´t mind because the town is tiny with nothing to do).. 12-13 hour days, with a q4 30-hour call day. This week I have to give an HOUR long presentation (IN SPANISH)...so that should be interesting. Every day I´m feeling more and more invested in this place and feel much more excited about medicine and health care than I have in awhile (the Peruvian hospitals killed my spirit a bit).. so life is good.
I celebrated my birthday here last week.. I happened to be on call so no libations were had (at least not yet), but I did buy a cake to share with the residents (the cake said ´´Happy Friday´´ because I felt weird buying myself a cake and then writing on it ´´Happy Birthday Tara!!). But that was good. Otherwise it´s been a lot of work and really not much play. Except, I guess, one night I convinced a few of the residents to go with me to the local karaoke bar (keep in mind that the town itself is like 3,000 people... tiny!!)... so there´s no way that people aren´t going to notice and remember the one gringa in town drinking and belting out American 80´s tunes... but I sang anyway (Total Eclipse of the Heart), and with full force like I was in front of a rowdy audience at the VFW in good ole uptown.. and it was awesome. I also gave a shout out to my lady Sarah Bazurto (a close friend from Madison who spent 8 weeks with me in Pedro five years ago when I was here for the first time... we spent quite a bit of time in the karaoke bar together back then singing Maná and learning to dance).. so I also sang a little Maná in her memory... holla!!!!
Life at the hospital is good. We start our days at 6:30 with basically a morning report where the overnight residents give a run down of all of the old hospitalized patients (I think it´s a 15 bed hospital.. usually we have 7 or 8 inpatients at a time).. plus tells the full story of the newly admitted patients, any transfers to Quito or other hospitals (HPVM is a ´´secondary care´´ hospital, meaning there are labs, xray, surgery, and inpatient -- at least some of the time.. but there´s no CT machine, there´s no ventilators--though they can and do intubate patients and then manually bag them in the 3 hour ambulance ride on the transfer to Quito), and they also tell about any interesting cases from the ER and then usually do a little teaching based off of that. I think it´s pretty productive, and it´s pretty interesting.
This is definitely a ´´tropical medicine´´ hospital -- I mean, we see a lot of crazy spider bites, snake bites (they have a whole protocol about how to approach this based on snake type, and the hospital houses a large collection of the snakes that people bring in after they´ve been bitten.. ahhhh!!!!), machete wounds, fertilizer intoxication (there´s not much oversight here for the use of pesticides.. and there´s lots of big farms around here... specializing actually in hearts of palm!!), weird infectious diseases, dengue, malaria (they do see but I haven´t seen yet).. and things related to the socio-economic status of many of the patients who live in inadequate housing with poor nutrition, no access to vaccinations or preventative care, etc.. But, the hospital and ER also see a lot of what we would call ´´normal ER stuff´´-- abdominal pain, kids with fevers, appendicitis, dislocated shoulders, broken bones, motorcycle and car accidents (I´ve seen FIVE 20-something year olds DIE from motorcycle accidents here.. nobody wears helmets and nobody drives well... SO SAD), and pregnancies and deliveries. In fact, I delivered a baby last night to a 15 year old girl...it was her first, but after observing her interaction with the father (who was there in the hospital but unable to tell us her last name or birthday.. and who sat and stared at the ground when she was going through painful contractions and sweating and begging him to fan her with a towel...) I felt pretty helpless and sad as I thought about the future for them and the baby. It was a good experience, though, because with the help of my resident we had to make a very large episiotomy which I had never done before... and we had to do everything, including cleaning the baby, doing apgars, weight/length.. everything the nurses do in the US... so that was good. This is a normal functioning hospital that is really making a valiant effort at meeting the needs of the people it serves -- and I`m really happy to be here.
The thing is, though... that it´s been somewhat hard for me to adjust to how things work here at times. For instance, there is only access to labs between 8am and 5pm (you can´t check a white count at midnight with a possible appendicitis patient or a Hemoglobin in a pale 30 year old pregnant woman with 3 days of vaginal bleeding but the inability to make it to the hospital because she lives in an area where a bus comes by once a week -- not that they have a blood bank, but still).. same with xrays. So any broken bone that comes in after hours... what do you do? How do you reduce a convoluted looking arm without an xray?? There´s no official ultrasound during the week... on the weekends a radiologist from Quito comes in and just does ultrasounds all day...(the hospital has a pretty decent machine but the residents aren´t trained to use it.. this is someplace where I feel like I could really be helpful in the future once I improve my ultrasound skills.. come back here and teach that!!). At times there is a surgeon but no anesthesiologist, or vice versa... so that´s obviously not helpful when you have an acute abdomen. In cases like these the only option is to send the patient in ambulance to another hospital -- most likely to Santo Domingo 2 hours away, or to Quito 3 hours away. It´s too bad, but as much as I hate it, there are limits to a rural secondary care hospital and that´s where I guess I´m struggling because I just want to be able to do everything and take care of everything ourselves and not ´´give up´´ the patient.. but only after 2 1/2 weeks am I coming to terms with the fact that we´re not Hennepin County... but I still feel like we cannot just give in and say, ´´oh, well that´s just the best we can do.´´
Case in point... I think that this hit home last week when we had a female patient 30 years old with two big (10cm diameter) necrotic lesions on her legs with obvious osteomyelitis to the bare eye. She also was clinically in acute decompensated heart failure. I won´t go into the details of all of the case but basically it took us 3 days to figure out she had severe rheumatic heart disease, neutropenic, needed a valve replacement STAT, and that she was hyponatremic. Why 3 days? On admission.. she came in after hours so basically there are no tools are available except your brain...we couldn´t get labs for 2 days, we couldn´t get an EKG because even though we had the machine it doesn´t show you the tracings and there wasn´t any more paper for it to print on (and there´s none available in town of course). We really could have used an echo but there isn´t anyone in the hospital that knows how to use the machine. So frustrating. When things finally got sorted out -- the differential included leschmaniasis, endocarditis, tuberculosis, amoebic liver disease, leukemia -- (I know, right... its a huge variety when you basically have no information???).. we decided that she had to be transferred to a bigger hospital with more resources because she required intubation, which we did, but there is no ventilator nor adequate meds for sedation etc. So, we transferred her by ambulance to Quito. The normal 3 hour ride took 6 1/2 hours because on the way en route was a large landslide (from all the rain we´ve been getting recently) that blocked the one road that leads to Quito. In the ambulance about 20 minutes before arriving at the accepting hospital, she went into respiratory distress then lost a pulse and later died. Such a sad sad SAD story.. and I can´t help but shake my head and wonder how things could have been different if there were different SYSTEMS in place to improve the management of this patient. Of note, when we got word of what happened in the ambulance (one of the residents went with the patient because she was so unstable and then informed us of her death), we informed the family of the news.... they then told us that five years ago she was in Quito for a valve transplant (despite repeated questioning to the family during her time at HPVM they NEVER mentioned this previous diagnosis???).. but she was unable to get it because she was unable to afford the $5000 cost. I´m not surprised, really, when the average income for people from this community is $1-2 per day. But such is life here, and I find myself struggling to accept that this is how it has to be.
On a much lighter note, however, they overall do have a lot of successes here with a thriving outpatient practice that does a LOT of preventative care and primary care stuff, lots of surgeries --appendicitis, gall bladder disease, hysterectomies, tubal ligations--, psychology, and consultants like ortho,urology,ultrasound/
When I do have time I´ve been exploring the countryside a bit with my ipod and tennis shoes.. I still can´t get over the fact that people here just think I´m a total fool if I go out for a run. It´s like I´m an alien or something and they just stare at me with this perplexed look on their face. HELLO I CAN SEE YOU STARING!!! At this point I don´t even care anymore and I just stare back or wave and I think that has loosened people up a bit. I´ve been taking the same route pretty much for the past couple of weeks, and the people that live along the road now wave back to me and the kids are starting to jog with me a bit, so that´s been fun. I also no longer get chased by dogs, so that´s a good thing. Over the weekend I went for a run and literally got chased by a cow, and that´s not a joke. It galloped after me and it was probably one of the most frightening experiences of my whole life. This particular cow and his friends had broken through their fence next to the road and there were like 15 cows on the road and there was nothing I could do but just slowly walk by them.. until one got pissed at me and charged, and I started sprinting. And of course they were hanging out on the road just around a curve where they would be completely invisible to any driver coming from either direction until it would be too late.. hello, does this scream Motorcycle Diaries to anyone?!!??!!?! -- and yes, that was my second reference to that movie in this blog. Oh, cows.
My time here is quickly coming to an end as I only have three full days left to work in the hospital ---whaaaa!!!!!! This weekend for Semana Santa (Holy Week) I don´t have to work (holla!!!) so I´m going to pretend like I´m Ecuadorian and do what the Ecuadorians do -- HEAD TO THE BEACH!!!!!! Should be a fun and relaxing time... and I´m hoping to work on the tan a little bit because contrary to popular belief, just because I´ve been in Latin America for 4 months doesn´t mean that I´m now brown... Cusco was rainy and freezing, and for the past month I´ve been indoors working during nearly all daylight hours. The beach will be a nice break, for sure.
I hope that everyone is well... can´t wait to get home and see you soon!!!!
Hasta luego, or as they say in Quechua in Peru ´´Tu pa nan chis cama´´ -- until we see each other again....
:)
Tarita
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