You want us to do WHAT?!

I've sat through some impressive board meetings, but I don't think we knew what we were walking into when Dr. Salamea and Dr. Martinez led us into the main ECU911 emergency headquarters of Cuenca, the third largest in the country, and asked for permission from the big wigs of the city for us to train their emergency personnel. We initially assumed coming down to Ecuador we would only be doing our research part and leaving the rest to the LATE students, but timing has worked its way in for our team of seven to be in charge of teaching MIVT presentations to nearly 400 emergency workers in the city of Cuenca starting July 18. It is an honor to be trusted enough to not only do the research, but use what we find to then improve a system with great potential.

After we left the meeting, our heads were swimming with questions. Are we qualified? What do we really know? Where do we start? Previous research and good mentors provided us with some ideas, and the doctors will be checking off the end product, but has been basically up to us to design our part of the implementation. We have decided to focus on helping the workers first understand WHY the information is important, then use the data to show where they've STRUGGLED, then teach MIVT BASICS and let them practice using real life examples. We will finish by handing out a basic presentation card to help them remember what the doctors have requested they present to help the hospital care be ready to go on patient arrival.

Example of the First Draft of the cards we will be handing out at the end of the course

 As we are winding down to the end of our research, we have noticed some common themes of information that is commonly, and very uncommonly, presented. Asking questions, we have found a common reason is that there has previously been NO training on MIVT. One of the ambulance companies, MSP, has a doctor that rides on it and has been incredible in helping us with the project. Through ride-alongs with him, we have learned a lot about the strengths and weakness of the system. Although he is extremely competent medically, the last time he heard about MIVT was in medical school, and has learned as he has gone what doctors want to hear. If a doctor doesn't feel like he has enough training, we know our part of the program will be vital in helping the rest of the workers understand it as well, which is why he has been supportive of our initiative. We are very excited to have the opportunity to teach what we have learned throughout the year.

A real example we plan to use in our training is about a man from Macas, a jungle city 8 hours by bus or a half hour by plane from Cuenca. After his car was basically run over by a bus on a Friday, numerous things went wrong in the communication by pre-hospital workers before he arrived to Cuenca by Monday night, including not even letting the hospital know they were bringing a severe trauma patient! With a fractured C6, ribs, and clavicle, a neck collar wasn't even placed for his bumpy ride, and he now only has sensation in his lower extremities. We hope this will prove the value of the training we are doing, as it could have been drastically different with proper workup prior to hospital arrival.

Though we work hard each night, we also play hard during the day. Here are a few pictures of our adventures. Que gara es Cuenca.

Before the Friday night storm...

After

On top of the New Cathedral in the center of Cuenca

Pumapungo, Incan ruins with a collection of exotic birds, anthropology museums, and delicious Belgian waffles

Project Update

We have been collecting data for just over a week now, and a research update is much overdue. 

Stage 1: Assessing MIVT from Ambulance Presentation at the Hospital

For the last week much of our focus has been on observing the presentation of MIVT upon arrival of ambulances at the emergency room. We have been splitting shifts with the LATE students, who are currently in the middle of finals, and have someone waiting at the ER for ambulances for 4 or more hours per day from about 3-11pm. While we are focused on trauma and medical emergencies arriving via ambulances, there are many who come to the ER by a family car or taxi. And even then, there are others patients that utilize the ambulances for transfers to the regional hospital, but are outside the scope of our study. These transfer ambulances cannot be distinguished from the ones we are looking for (and they seem to come more often), so we have had to learn not to get too excited when we see the red and blue lights pulling up. While the ER is consistently busy, we have been a little concerned by the lack of data points we have been able to collect for this stage of the project (on average one data point for almost every 3 hours). As researchers we would love to have more data considering our timeframe, but as humans we realize our limitation is just the norm for our location.

A well-used checklist to assess MIVT (used at every leg of the communication tree)

Stage 2: Assessing MIVT from ECU911 Central to ECU911 at the Hospital 

Normally, an ECU911 employee at the hospital presents a form (from information received from ECU911 central) to the doctor informing him/her of an incoming patient, and the doctor signs the sheet. This information is eventually stored in a database. We initially hoped to gather data from this database, but were recently informed that information was sometimes written in later in the day. As such, it makes more sense for our purposes to collect the information soon after it is received, and are currently making those adjustments.

The form used by ECU911 representatives at the hospital to inform doctors of an incoming ambulance

Stage 3: Assessing MIVT from Ambulance to Doctor at ECU911 Central

Our tour of ECU911 Central this last week gave us more insight into the Ecuadorian emergency system. Housed in ECU911 central is a massive dispatch room with all the public services—police, military, fire, EMS—with the EMS dispatchers sitting in the back row. These agencies include MSP (Ministry of Public Health), IESS, firefighters, and the Red Cross. MSP and IESS, the government public health services, each have a doctor and paramedic that help triage and relay information received from ambulances to their receiving hospitals. Whereas in Richmond, Virginia ambulances call in directly to the hospital, in Ecuador, the ambulances usually only contact ECU911 central (who then relays the message to their representatives at the hospital). There have been a few snags with permission, but we plan to use the LATE students at this station to listen in to the radio calls from the ambulances starting this weekend.

Following our first tour at ECU911

Stage 4: Training Course for EMS Personnel

Yesterday we went with Dr. Salamea to present our project and implementation plan to all of the government services at ECU911 central (including the police, firefighters, military, EMS, and the director of ECU911 in Cuenca). We were well received by the group, but as in any bureaucracy, progress can be slow. The director of MSP EMS in Cuenca had been planning on conducting a course for EMS personnel, but following a 5 minute meeting with Dr. Salamea in the hallway, he was able to push for the addition of an MIVT course to the training...and for it to start next week (we should have the presentation complete by the end of the week). There are still a few hoops to jump through, but we should be conducting training courses with the LATE students by next week for about 400 EMS personnel around Cuenca. Amazing.

Following our meeting at ECU911 with (from left to right) Mark, Jeremy, Dr. Salamea, Elissa, Emmy, Dr. Martinez

La Vida Cuencana Que Tenemos

One of my favorite parts of traveling is getting involved with the culture and finding out what is important to the people in that part of the world. I remember watching Indiana Jones as a kid and wanting to be that guy that could walk into a village and instantly connect with people (yes I may own a hat and whip). So apart from the salsa pictures we already posted (highly edited to not dissuade our viewers from following) here are a few of the other things we've been up to:

Visiting the Centro and trying foods. Sanduche de Pernil is a personal favorite.

We went to a Cuenca soccer game with Pepe, one of the LATE students we're working with. Dressed in the local garb ($5 street side jerseys), we had a blast, especially towards the end. The stadium wasn't in a good mood as the home team was down 3-1. After scoring on a free kick in the 85th minute to put us down 3-2, the opposing goalie, who had been flopping the whole game, decided to hold onto the ball. Our star defender wasn't having any of that, so logically communicated that with a swift right hook to the face. Both players ended up being ejected, setting up a wild finish where Cuenca was inches away from tying the score on a bicycle kick from the top of the box. Time then ran out, but not before we had a blast.

Ask any Cuencano and they all say the same thing: Cajas National Park is a must see. Just 45 minutes outside the city, we found ourselves hiking at 14000 feet with swirling fog, a beautiful lake, and gorgeous views of the steeper-than-you-can-believe Andes. Pictures nor words can really express the incredible beauty we experienced. Or maybe it's just that we're out of breath from the altitude.

Spending the day with your adopted Ecuadorean family eating fish would be amazing enough. But what if you also got to catch those fish? Sandro took us up to a stock pond, where the fish were the hungriest I've ever seen. We're not even telling a fishing tale when we say the longest it took to get a bite was 5 seconds of water time. Trust us, we did the research, it's what we do.

But of course, one must never forget their own culture. What's more American than Big Macs, KFC, and greasy pizza? God Bless the USA and all our supersizing. Happy Fourth of July from Cuenca, Ecuador!

Independence Day Weekend

What's more American than fishing, country music, and grilling? Well...does it still count if we do it in Ecuador? Either way, we had a great Independence Day weekend enjoying the country, and checking out the Cajas mountains (absolutely PHENOMENAL btw).

But when you throw four medical students together for a couple hours, of course the topic will come back to around to ...school, trauma leagues, etc. This entire trip, we've been trying to keep our objectives in mind (thanks, Jeremy!). We realize how important it is to understand the implications of our project, how it fits into the big picture, and whether or not it will have real life implications. We don't want to do research for the sake of research. We want the results to fill a necessary need in the system. There's a lot of waiting time in the ER in between all of the ambulances. We're trying to best utilize that time and have been learning medical Spanish, shadowing in the ER, and just observing the ER process in general (from patient arrival to patient treatment). Every time you start a research project and get deeper into it, more and more questions arise.

It was interesting to see how people got to the emergency room. We spent hours on hours waiting for emergent ambulances, only to get roughly one ambulance for every three hours. Most ambulances that arrived came with patient transfers from other facilities. Instead, it seemed like most people arrived at the ER via their own vehicles or taxis, even if it was trauma related. I asked Sandro about this, and it seems like an issue with the EMS system is related to their response time. When people call 911 for an ambulance, they have no idea if it'll take 10 minutes or 30 minutes for an ambulance to arrive, whereas if you flag down a taxi, you get immediate transportation. Even the idea of calling 911 is a relatively new concept. ECU 911 was established four years ago. Before that, patients had to call individual organizations to get help, all of which had individual dispatch systems - making the process disconcerted and unorganized. There was a separate number for firefighters vs ambulances vs police. With ECU 911, it unified the system. There are billboards all across town publicizing the system and making it well known. In just the last four years, there have already been huge advances forward, so it'll be interesting to see how much more public opinion changes towards the system in upcoming years! As for the response times, we're still not sure why it takes a while, we had a lot of brainstorming: where are ambulances stationed throughout the city? Is traffic slowing down the ambulances, as in do drivers not move for sirens? Are addresses difficult to find? what is the actual response time - are they actually long or is that just public perception? We're not sure, but we'll try and find out as we learn more and more about the system!