Reflecting on my trip

In October, 2011, I had the unforgettable opportunity to participate in Child Family Health International's Reproductive Health program in Quito, Ecuador.  As a fourth-year medical student, this was a great time for me to to an elective abroad.  I learned about CFHI at the AAFP National Conference for Residents and Students where they gave me a free t-shirt.  It wasn't until two years later, when I began to seriously consider an international rotation, that I learned about the variety of well-developed programs that they offer.  I chose this program because I am interested in family and community medicine, and particularly enjoy Women's Health and Pediatrics.  Reproductive Health in Quito combined my medical 
interests with the opportunity to improve my Spanish skills, which will be very valuable as I move forward with my career.  I applied for the scholarship through CFHI, hoping that it would make funding my trip more feasible, and I am very thankful for the financial assistance. Also, if it hadn't been for the scholarship, I might not have kept as detailed journal/blog entries or taken as many photos, and I am happy to have these to share with my family and friends, and future participants.  

One whole month seemed like a long time to be away when I was preparing for my trip, but the time actually flew by.  We spent every morning during the week working in the clinic or hospital, and rotated to a different site each week.  For the first two weeks, we attended Spanish classes at the Amazing Andes Language School all afternoon.  I had only had a brief Medical Spanish course before my trip, but I studies a lot on my own and was able to place into the "intermediate" Spanish class.  These classes provided lessons on grammar as well as Medical Spanish, and often focused on medical terms that were relevant to our particular clinic sites (maternity hospital, pedicatric clinic).  Following class, we would have some free time to run errands, or just return home to relax.  We had dinner

at our home-stay every night at 7.  Following dinner, we were often busy with homework or studying Spanish, but we also had time to go out or stay in and talk with family and friends back home.  After working all week, we had all of our weekends free to travel and take in all that Ecuador has to offer (there's plenty on that in previous blog posts).

As I stated above, I have always been interested in Family Medicine and Community Health, so it seemed natural to get involved in activities that provide services for people who are medically under-served.  Throughout medical school, I worked at our Free Clinic for the Uninsured and learned about how we can utilize resources to help provide medical care for people in need.  In Ecuador, all people have access to free healthcare, but there is a great disparity between the quality of facilities available to the wealthy and to the poor.  In all of the public sites that I worked, doctors repeatedly told me that certain things weren't available, because there was no money.  This was most evident in the maternity hospital, where laboring patients didn't even have sheets or pillows on their beds.  Still, with limited resources, all of the doctors I worked with provided invaluable services to their patients by focusing on small ways to improve health, such as making sure vaccinations were up to date, providing education about nutrition and contraception, and promoting breast-feeding.  

Looking back, I feel that this program added a vital dimension to my medical education.  My school places a lot of emphasis on cultural awareness in the curriculum, but learning about different cultures in a lecture hall cannot compare with being immersed in a culture for several weeks.  I feel that after this experience, I will have a better understanding of the experiences and values of my hispanic patients and hopefully will be able to make them feel comfortable.  Finally, after having to navigate a foreign country, I have a newfound respect for all people who have emigrated to the US or speak English as a second language.  As I move forward in my career, I would like to continue to learn and practice Spanish, so that I can communicate clearly with more patients. I would also like to incorporate international rotations to South and/or Central America into my residency training and future career so that I can continue to explore different cultures while providing much needed services.

Week 3 Clinic - Carcalen Bajo

Carcalen Bajo


First, I apologize that there are no pictures to make this post more exciting.  


I spent my third week of clinic working with a family physician at a public clinic on the far north side of Quito.  The bus ride took over an hour, and required switching buses at the bus station, but it was kind on neat to see another area of the city.  Clinic patients were seen on a first-come, first-served basis, and the vast majority of them were children.  Many of the children came in for "control del nino sano" or CNS visits, which are the Ecuadorian version of a Well-Baby or Well-Child exam.  This provided a great opportunity for me to perform exams, and review stages of development.  A number of children also presented with common complaints such as cough, diarrhea and constipation.


Many of the children with diarrhea and constipation were given dietary advice, as they were often drinking too much juice or taking in too little fiber.  One 4 year old boy had presented with diarrhea earlier in the week, and returned to the clinic a couple days later after giving a stool sample.  His test was positive for roundworms (ascariasis) and he was prescribed albendazole for treatment.  This case brought up and interesting discussion, and we learned that parasitic infections are so common in Ecuador that the general population takes a prophylactic dose of albendazole and secnidazole every 6 months.  This was also personally relevant, because as visitors to the country, we had to take the same medications as soon as we returned to the states.  Yikes!

A number of children had coughs, and the Doctora often attributed this to the change in the weather.  October is the start of the rainy season in Ecuador, and evidently it is pretty common for people to experience cold-like symptoms during this time.  

Finally, we were in the clinic during one of their vaccination days, and were able to spend time with the nurses while they administered the pneumococcal vaccine to many children.  It was interesting because the mothers would bring their children into a room where the vaccines were given, and there was a long line waiting outside.  Unfortunately, each child in line would then witness the vaccination of the child before them, and would be screaming even before they sat down.  Additionally, the nurses didn't make an effort to hide the needles, which only added to the fear factor.  It seems that since the vaccines are only available in the clinic on certain days, they just need to make sure they can get through as many children as possible.

Overall, this was a great week.  I learned more about Ecuador's public health system and how it effects children and families in the country and some of the common health problems that children face.  This week was also very helpful because I really felt like I was able to understand more Spanish, and participate more with the patients.  Those language classes were really making a difference!

Sightseeing in Quito

Final week in Quito

We were still working in the clinics every morning, but since Spanish classes had ended, we had our afternoons free to explore the city.  We spent one afternoon walking around the "Old Town" area, where there are endless colonial churches and buildings.  We visited a monestary called Santa Catalina, where they have a large collection of religious art, and the cloistered nuns make wine and natural soap.  

Monestery of Santa Catalina

Jana couldn't resist ringing the bell after we climbed up the bell tower.

Beautiful view from the tower

A brief glimpse inside the church at Santa Catalina

After the monastery, we walked to Plaza Grande, which contains the Presidential palace, the Archbishop's palace, the Municipal palace, the National Cathedral surrounding the Monument to the Heroes of Independence.  Unfortunately, shortly thereafter an afternoon downpour came and ended our city explorations for the day.

National Cathedral in Plaza Grande

Plaza Grande and the Monument to the Heroes of Independence

The next day we had much better weather and decided to head just north of Quito to the monument at the equator, know as Mitad del Mundo.  This large monument was built where the equator was calculated to lie 1743.  Turns out, according to GPS, that the true equator lies a little farther north.  There is another museum that claims to be at the true equator as well, but I was disappointed that I didn't have my own GPS to prove it.  

Mitad del Mundo!

Our tour guide claimed that it is easy to balance an egg on a nail when you are at the equator because the forces that pull in the direction of the poles are perfectly balanced there.  Not sure I believe him, but how else would my clumsy self accomplish this?

And I have a signed, stamped and dated certificate to prove that I did it!

Last day out in Quito:  Our house mom hired a driver to take us to see a few of the sights that are not easily accessible by bus or on foot.  First we rode way up to the Templo de la Patria, the miliary museum that overlooks all of central Quito.  From up there, you get a sense that the city goes on forever .  

Quito from above.  The green area in the middle is known as the panecillo (little bread loaf) and the Virgin of Quito lives on top of it, watching over the city.

View from the Templo de la Patria

Jana, Me, Sue and The Virgin of Quito

Thats pretty much it!  Oh yeah, there was also the part where I got super sick, but let's just say I will forever be grateful for the healing powers of ciprofloxacin!  Don't leave the country without it!

Week 4 Clinic - CEMOPLAF

CEMOPLAF


First off, I once again must apologize that there are no pictures, but I was having some technical difficulties with my camera battery by this point in the trip.  Also, this week's clinic experience was limited to only a few days because I became very sick at the end of the week and couldn't go in to clinic.  Despite all this, I did really enjoy my experience here working with Dra Paredes.  


CEMOPLAF stands for Centro Médico de Orientación y Planificación Familiar.  This clinic focuses on family planning, but I spent my time working with a pediatrician that sees mostly infants and young children there.  This experience was very similar to the previous week.  It is a public clinic, and once again, patients were seen in the order that they check in.  We did many Control del Nino Sano exams and had many patients with common colds and coughs.  One difference between this clinic and Carcalen Bajo was that Dra Parades seemed to have an almost limitless supply of medications that she was able to give directly to the patients, instead of them having to go to the pharmacy.  Several times during clinic, drug reps would pop in and provide her with samples of different medications.  I thought this was a great advantage, because it made her instructions for taking the medications more clear when the parents had the medication right there in front of them.  

Doctora Paredes always focused on the importance of a healthy diet, and this was a major part of her interview questioning and teaching during Control del Nino Sano exams.  She was always careful to ensure that her patients were getting the right foods at the right times, and getting enough from the different food groups.  I noticed a food guide pyramid specific for Ecuador in her office, as well as several others.  This roughly follows our old pyramid model and interestingly includes 8 glasses of water as well.  

http://portalecuador.ec/module-Pagesetter-viewpub-tid-15-pid-10.php

As I mentioned above, CEMOPLAF is one of few places in Ecuador focused on family planning.  They actually have a partnership with Planned Parenthood, and provide a lot of much-needed education and services.  Here's this link to their website if you're interested in learning more: http://www.cemoplaf.org/.

Cuenca, Ingapirca, Montanita and Puerto Lopez

Our last weekend adventure...

After working hard in the clinic all week, we soon realized that 3 weekends and a few free afternoons does not provide anywhere near enough time to see all of the amazing sights that Ecuador has to offer.  Our last trip was thrown together as a last minute effort to experience as much as possible.  

We started our trip with a short flight from Quito to the southern colonial city of Cuenca.  We spent our first night there and were so happy that we had the chance to meet up with our friends who came all the way from Puyo to join us.  Our first priority was to see the most well preserved Incan ruins in Ecuador, a site called Ingapirca that is about an hour away from Cuenca.  The five of us squeezed into a cab that took us on a beautiful scenic drive to the site.  

Ingapirca, Ecuador

Sue, Cristina, Jana, Me and Chloe standing in front of the temple of the sun.

Temple of the sun

After Ingapirca, it was back to Cuenca for some more sight-seeing.  The architecture is stunning and gives the city such a romantic feeling.  Of all of this places in Ecuador that we visited, this was the one place where I felt like I could actually live.  The people were nice, the food was great and there was no pollution or crowded streets.  It was definitely a more relaxed feeling than Quito. 

So many beautiful cathedrals in Cuenca.

We were sad to leave Cuenca and our friends from Puyo, but the next stop of Sue, Jana, and I was the beach!  We rode the bus all the way to the coast to the famous surfing town, Montanita.  Apparently there are annual surfing competitions here and this is where surfers come to practice (and party).  The town was pretty quiet during the day, and it really appeared that everyone was at the beach.  I'm not a surfer, but I loved boogie boarding when I was a kid, and this was the perfect place to try it again.  So much fun!

Amazing beach at Montanita.  Don't let the clouds fool you, the sun was hot!

Our final destination was supposed to be Isla de la Santa, also known as the "Poor Man's Galapagos."  Unfortunately, we arrived at Puerto Lopez too late in the morning and missed the boat...literally.  Since we were already at the port, however, we decided to take a tour of a closer island, Isla Salanga.  It was definitely not what we were expecting, but we played with crabs on the beach, learned that hot sand helps take away the pain from jellyfish stings and I got to drive the boat back into the harbor.  Most importantly, we finally did get to see some blue-footed boobies!

Frigate birds going for some fish

Sure, its not the best picture, but that is a blue-footed boobie!

Otavalo, Ecuador - Oct 14-16, 2001

Parade of people in costumes and traditional indigenous dress

Otavalo, Ecuador 


As soon as we arrived in Otavalo, we were greeted by a parade!  I'm not exactly sure what is was for, but it was cool to see the costumes and traditional dress of the people as they walked through the street. 


After our visit to the indigenous clinic in Otavalo, we decided to stay for the weekend and do some sightseeing and shopping at the world-famous market. The people of Otavalo are known for their weaving and knits, most of which are made from alpaca.  The market fills a huge space in the center of town, and on Saturdays, even the streets leading to and from it are filled with vendors.  


The market has tons of food, including produce, grains, bread, spices and vendors selling prepared food and drinks.  

One of many whole roasted pigs at the market and a lady making "tortillas, " which here means a fried potato cake.  Yumm!

Bread!

Spices!

Grains and beans!

Fruits!

Veggies!

The crafts in the market are the other main attraction, and where we spent most of our money.  I hope I have room in my suitcase for all of the souvenirs! 

Sue checking out the hand-crafted guitars

Tons of sweaters

An Otavalan woman in her traditional dress with the knit hats she makes

Another indigenous woman with her knit hats.  That's SpongeBob on the left!

After a long day of shopping, we decided to try some of the local fare.  This is a traditional plate that consisted of fritada (small pieces of fried pork), mote (hominy made from choclo, the special type of corn that grows here) and at the back of the plate, tostada (crunchy toasted and lightly seasoned corn) with a salad and a potato.

Fritada con mote y tostada

Week 2 Clinics - Maternidad and Jambi Huasi

"Maternidad"

Maternidad Isidro Ayora, Quito

Ecuador has public healthcare for those who can't afford it, and Maternidad is the largest public OB/GYN Hospital in Quito.  Also, all elective abortions are illegal in Ecuador, and the unintended and teenage pregnancy rates are high.  I was told that this hospital is largely funded by the medical schools in Quito, who send their students there for training.  I assume this to be true, because of the number of students that cram into the Salas de Partos (Delivery Rooms).  

Initially the biggest difference between this hospital and those in the US was that there were so many patients in one room, all of them laboring together.  One morning I counted 13 patients packed into the main room!  The patients would stay in this room until just before they were ready to deliver, and then be hurried to a delivery room that was basically an operating room.  These rooms were sterile, contained no comforts and the patients were not able to have any family present during labor or delivery.  Often, there would be 8 or more students lining the walls of the room trying to see what was happening as the residents delivered the baby.  

Most patients are not on continuous monitors, but they are available when needed and used intermittently.  Residents and students often stood at the patient's bedside with one hand on the patients abdoment to feel the contractions, and the other setting the timer on their cellphone to measure the frequency of contractions.  The most interesting intsrument that I was able to try was a coroneta de Pinard (Pinard stethescope).  This is used to listen to the fetal heart beat.  Hand-held dopplers were also available, but not very commonly used.  

Pinard Stethescope
http://www.mumstuff.co.uk/acatalog/pinard.jpg

Another large difference was that at this hospital, epidurals are virtually non-existent because they do not have the anesthesiologists available to give them, even when a patient could really benefit from it.  Following the delivery, they would just get some local lidocaine if they needed a few stitches.  Other commonly used drugs were oxytocin (given IV only for significantly prolonged labor and given as a IM injection to all women immediately following birth), misoprostil, and magnesium sulfate.  Amazingly, the women on IV magnesium sulfate were not on cardiac monitors!  I was assured that they checked reflexes regularly, and since loss of reflexes occurs at lower concentrations than arrhythmias, this was safe.  

I spoke with several students, and they informed me that at the private hospitals, each patient has their own room for labor and delivery, and that the family is usually present, which is similar to the US.  

Jambi Huasi

On Friday, October 14, we had the privilege of going to the indigenous clinic in Otavalo called Jambi Huasi.  Otavalo is a town about two hours north of Quito that is home to many indigenous people, and a famous market where the sell their goods (check out my next post!).  The desire to preserve traditions in this community and the need for adequate health care for the town lead to the opening of this clinic, which combines Western medicine with the ancient traditions.  We watched as one of the traditional doctors treated several patients.  It was interesting to watch the techniques used by the doctor, but it was also challenging because she and the patients often spoke in Quichua (indigenous language mixed with some spanish) and it was very difficult to understand.  

Jambi Huasi Clinic

View from inside the clinic's courtyard

The most well known procedure practiced in this clinic, and in only a few remaining places, was a diagnostic procedure that uses a cuy (guinea pig) as a medium.  We had one patient who came to the clinic because he was having back pain, and he wished for the doctora to diagnose the problem.  She rubbed they cuy vigorously all over the patient's back, chest, abdomen, arms and head.  (Apparently, at this point, the guinea pig is either dead from suffocation or comatose from severe cerebral edema.)  Then she skinned it and opened its abdomen to analyze its organs.  After much analysis, she stated that there wasn't anything seriously wrong and she recommended that he get massages for his back pain!  I understand the importance of preserving this type of traditional medicine, but it seemed unfortunate that an animal was killed for what seemed like a very simple problem with a simple solution.  

In addition to the "Cuy X-ray," the clinic offered colonoscopies, EGDs, tuberculosis treatment, family planning, massages, mainstream medicines and many herbal remedies.  We were able to walk into the herbal medicine room and take pictures, but unfortunately the "pharmacist" wasn't to interested in teaching us about his craft. 

Traditional medicinal herbs

Guide to herb identification plastered to the wall

More herbs on the wall, as well as quite a few animal skins

Overall, it was a week full of new experiences.  I learned a lot about the differences between healthcare in private and public hospitals in Quito and hospitals in the US, as well as some of the forms of traditional medicine practiced by indigenous people in Ecuador.