Seremos Cuencanos Ya

Regional Hospital Vicente Corral Moscoso...where we spend ALL our time

EMT Elissa chatting it up with a Bombero on the ambulance.

The ER waiting room enjoying the Italy/Germany shootout in the UEFA cup. A picture is worth a thousand words--even the need for healthcare stops when the game is on the line.

How to get 15 prisoners out of jail for the night...swallow nails and screws of course. A whole group of these guys came in Friday night. We finally asked what was going on and got this picture above (check out the bolt).

 

A little cultural exchange at the Cabrera household--can't say enough good things about our hosts.

Additional First Experience in the ER

It was an eventful and eye opening experience last night in the emergency department at Vicente Corral Moscoso Hospital. We figured we would be able to see a few ambulances between 4pm and midnight, but we saw a whole lot more. Around 8pm the masses started arriving, and the emergency started to fill up beyond capacity.  With about 12 beds in that part of the emergency room, and many more wanting to be seen, medical students, interns and attending physicians were constantly busy patients treating, suturing, and organizing the room to meet the demand outside that seemed to never stop. Specifically, I woke up this morning thinking about a woman I will call Sofia—an 86 year-old woman that suffered an unfortunate fall that resulted in a massive lesion to the top of her head. The first time I saw her was around 8pm, while laying in bed #10, wrenching in pain. Sandro was on shift, and let me help by grabbing materials for him. Essentially the interaction went like this:

Sandro, “Could you get me a #10 needle?”

Me, “Sure, come se dice needle?”

Sandro, “Aguja.”

Following that, I would search the unfamiliar emergency room using my very broken Spanish in search for the said item (#10 aguja, bisturí, guantes, and on and on). This type of interaction happened multiple times, and by the end of the night I felt okay with our new surroundings. Thank goodness for the nurses and other staff that were kind and willing to help out a Spanish-deficient gringo. In the end, Sofia’s head was sutured up and the last I saw of her was at midnight when we left, lying in bed #10 with her children at her side. 

Before our first night in the ER, Sandro showed us around centro de la ciudad. Left: In front of the governor's mansion, Elissa buying sweet empanadas from a street while Mark was playing tourist. Right: the gang in front of the new cathedral of Cuenca.

A night in the ER

Do I hear a siren... Or a car alarm? I think I saw the reflection of an ambulance’s red lights? Or maybe it was just a trick of the light? I don't think I've ever looked out for an ambulance so keenly as last night. And so that began my first night shift at the HVM ER. 

And what a night it was! There were nurses decked out in perfect white trying to put pressure over hemorrhaging wounds (how much bleach must they need here?!), doctors dashing out to the pharmacy to grab necessary supplies, and patients being wheeled in and out to open up spaces in the ER. The LATE students definitely knew what they were talking about when they said that traumas on weekend nights would pick up. 

Unfortunately for us however, all of the patients were arriving via taxis and cars (another question in of itself! Why are patients choosing not to call the FREE ambulances to get to the hospital??) It's hard to study an EMS system without the EMTs! We were able to collect more data but just not quite the sample size we were hoping for. Collecting enough samples is going to be harder than expected, but every research project comes with its hiccups.

On the other hand, in terms of a medical experience, it was incredible. It was awesome to get a chance to observe an Ecuadorean ER in full swing. It was a mix of the old and the new. It was the same policies that I was familiar with in the US, just with slight twists adapted to the hospital. In Ecuador, there is free healthcare for everyone. There are public hospitals and private hospitals. HVM is a public hospital, and it has limited resources. According to Sandro, our LATE host, at HVM, you just learn to work with what you have, whether that be a shortage of hydrogen peroxide, dull sutures, or simply not enough space.

Last night, I got to follow a patient from the start. He arrived on a backboard with the EMTs. With a Glasgow score of ten, he wasn't very responsive but still flinched to pain and tried to fight off the pulse ox. As the doctors rushed to find a room, it was touching to watch the EMTs stay with him. Despite the country, EMTs play the same role of patient stabilization and patient comfort. I watched as an EMT touch his hand, to try and reassure him.  After the transfer, we followed him to imaging (CT, X-ray, and ultrasound). Everything that we had learned about in class, now in action! Sagittal views, Coronal views, transverse views. An X-ray to check for hip fractures, a huge source of bleeding. Ultrasound, to check his internal organs. 

"Que Gara": Cuencan for "That's Cool"

Every day seems long but every day brings some good along the way! It's fun working with fellow students that are as anxious to be pushing forward as much as I am. The medical students we are working with are actually in the middle of finals, which makes coordination difficult, but they have been very willing to be involved and extremely helpful. The biggest success of the day was when we found that one of the three legs of communication we would be studying, the ambulances to the hospital, actually keeps a database of everything we were thinking we would have to listen in on. So after using my utmost verbal skills with Latino women and a Twix bar to obtain the excel sheet, one of the three legs will just be transferring data. Check. We did find, however, that waiting for ambulances midday is...fairly useless. After collecting data from one ambulance in 2.5 hours, we decided to move shifts to the evenings, especially on the weekends, when there is a lot more traffic. The LATE students are on board and things are looking great.

Paper used by ECU911 at the hospital to organize information of an incoming ambulance.

Speaking of LATE, we were privileged to go to their annual review and election meeting and learn of the incredible things they are doing. They are a student organization of trauma and emergency medical students that are doing amazing educational things in the community while becoming skilled acute physicians already. We were thoroughly impressed, and are not alone, as they have been recognized internationally as well with Dr. Juan Carlos Salamea, chief surgeon of Ecuador and one of our research mentors, at the head. Sandro, our host, actually became one of four presidents for the next year at the meeting, and we met some of the students there.

Otherwise we are throughly enjoying Cuenca and the its people, culture, food, and beauty. An accidental long bus ride home was actually very fortunate as we got up above the city and were able to take in some breathtaking views of the homes and many many churches. Elissa and Jeremy are coming along very quickly with Spanish comprehension, and my tongue is getting back to rolling the r's and hitting the accents slowly but surely. What an incredible opportunity.

It's not bad getting stuck on a bus (only a 25 cent tour) when it includes beautiful scenes like this. 

- Mark

Vamos a Cuenca!

 Team Awesome ready to start the action, Regional Hospital Vicente Moscoso

 At Turi, the ultimate Cuenca lookout, with our incredible LATE host Sandro

With Emmy and Caro, two of our four Ecuadorian colleagues for the project, both LATE members

Let the journey begin! After all the work we've put in before, we're excited to let the project begin in Cuenca. Elissa arrived on Sunday afternoon to an incredible welcome, and after a night in the Quito airport and getting rerouted to Guayaquil due to weather, Jeremy and I finally got into one of the most beautiful cities I've ever seen. Many old churches, misty mountains, multiple tortuous rivers running through it....Cuenca is such a hidden gem. The real gem, however, has definitely been the people. Sandro, a medical student and member of the LATE trauma league, has been the best host we could have asked for. Emmy, Caro, Fernando, and Pepe, the four trauma league students assigned to assist us in the research, have also been amazing in helping us get to know the city and prepare for the project. We couldn't be more excited.

The past two days we have been getting to know the city and the trauma system with which we will be working. Previous research by our fellow ITSDP colleagues and other LATE students had pointed to communication as a key barrier to the Cuencan trauma system functioning at full capacity. In our meetings with Dr. Juan Carlos Salamea, Dr. Alberto Martinez, and the LATE students, we have organized our upcoming schedule. We currently plan to work on a before and after comparison project with a training program in between focused on the holes we find. The objective data we collect will come from a "yes" or "no" checklist we have created to see if the MIVT presentation ambulance personnel should be communicating at multiple points in the chain. This data will then be used to focus the training for the EMS workers on where they are lacking in the presentation. The follow up study will see how the training improved their performance. We hope to begin the first aspect of the project tomorrow with the help of the students and are beginning the preparations for the training. What an exciting time to be in Cuenca!