Ha-BLAS es-PAN-ol?

The three of us are pretty outgoing people. We're the type of people to talk to everyone we meet, from the taxi driver on our way to the hospital to the waitress serving us lunch. And, I think that's what's made this language thing so much harder than expected.

After spending two years in Mexico, Mark is fluent in Spanish. Jeremy and I, on the other hand, had a lot more to learn. Jeremy took two years in middle school and I took Spanish through middle school until 10th grade. To put it lightly, it had been a very very long time since either of us had seriously studied Spanish. I was actually amazed by what came back, who knew so much from sophomore year of high school actually stuck! I was never especially good at Spanish then, which made this even more surprising.

When I got to Cuenca, I knew for a fact that I wanted to take Spanish classes. At $10/hour for a private class, I figured it was well worth it, in order to best accelerate the learning process. Whenever interacting with Dr. Salamea and the other LATE students, we spoke solely in Spanish - something I really appreciated. It forced us to get into Spanish and taught us a lot of medical Spanish.

By the end of this trip, I would say that I'm now at an intermediate level of Spanish. I can understand what people are saying and I can say whatever I need to say (I've gotten really good at word origami - rephrasing my sentences whenever I don't know a word to best utilize my current vocabulary). That's where the problem is, though. For me, it's been really hard to get to know people well when you can't joke with them, and when you can't have conversations at a deeper level than your average daily chatter. There's a difference between being capable of communication and being comfortable with using word play and irony.

I feel like it's generally believed that your personality is an inherent part of who you are. But here, I've found the opposite - I actually think that talking in a different language can actually change your personality. Mark and Jeremy watched me as I spoke with some Chinese tourists in Cantonese. They said that my whole body language changed when I spoke in Cantonese, and my demeanor did too. In Spanish, I'm much quieter, whereas for Mark, it's the opposite, and he's actually much more outgoing in Spanish! At the end of the day, it's actually exhausting to have done nothing but speak in Spanish. Your mind is cranking nonstop and constantly on the move. It made me less likely to strike up conversations with random strangers, because I just got tired.

This was really eye opening. Growing up speaking English in an English speaking country, I never really seriously considered language barriers on social relationships. I knew they were an issue when someone couldn't express what they needed, like medical help in a hospital or were lost and needed directions. But, your confidence in your language abilities can also affect so much. My parents immigrated to the US in their twenties. They're fluent in English, give or take an Asian accent, but they've never chosen to speak English at home. They feel more comfortable when speaking Chinese, and now I can better appreciate a sense of why. It's difficult to get the same easy going joking going on in a foreign language. So many jokes and conversations revolve around word manipulation (puns, etc), lingo, and cultural references specific to the area.

Despite acknowledging this hurdle, I feel like we've gotten to really know our LATE friends. They've taken us to soccer games, hiking, and many more adventures. One of my favorite memories was when we went hiking with Caro, one of the LATE students we worked with. We took a bus around town to get to Giron, where we then walked 6km alongside some beautiful countryside before finally getting to start our hike (or should i call it a vertical rock scramble) up along the side of a waterfall. We spoke Spanish the whole day, and it was great to get to spend the whole day with her, away from the pressures of time and school. No matter the country, med school is the same. We joked about our classes, how stressful studying is, what we want to do with our futures, etc. (funnily enough, she taught us the word "maton"...which literally translates to gunner - some things just don't change!)

For me, language was a huge part of this trip. Getting a chance to learn Spanish (especially medical Spanish) better is a great skill to have. Furthermore, the international perspective on the familiarity of language is enlightening.

Insights on Health Care in Ecuador

Whenever you visit a foreign country, especially for health care, there are certain pre-conceived notions you have on arrival. In my previous medical travels through South America, I have generally found these notions to be ignorant and false. For example, the first time I was in Ecuador, I remember being extremely impressed at the level of primary care provided to patients. Everyone had their mammogram, shots, and physicals up to date (or at least those that were coming to see us in the free clinic). Some of the more surgical and emergency cases, however, appeared to be in need of improvement. As we have observed the Ecuadorean system during our research time, I have made it a point to ask opinions of everyone in the chain how it is working and what can improve. The following is not meant as a critique, as I have been very impressed with what already exists and is currently improving, and more as an insight into what we are helping progress here in Cuenca.

Health care is considered a right in Ecuador and is free to everyone, including myself if I happen to fall climbing a waterfall (see below, don't worry the fall never happened, but I do know the entire EMS system if it did). They also have a second tier option, which is insurance purchased by your employer through the government and allows entrance to a different hospital, followed by a third tier which is private. With everyone having access, basic care is being wonderfully taken care of. However, many physicians have complained about the lack of resources to treat as many emergent patients as come through their doors, especially on the Friday nights we have been there, where 20 patients can be standing in a room of eight beds. The regional hospital where we have been observing has sixteen surgical/clinical emergency, three trauma, and seven ICU beds to cover two million people. These numbers can push things back down the chain, where an ICU patient must wait in the trauma bay, making a trauma patient wait in emergency, making the ambulance that just arrived with a car accident wait in the hallway until it can enter emergency. Rather than giving a negative impression, I am actually amazed with what is done. If I am ever in a crisis, I'll take the Ecuadorean doctors I've been working with, who are geniuses at making the most out of their limited resources. I have gained respect for the level of care they are able to provide in whatever circumstance they are placed. As the resources continue to come in, and they will for a nation on the rise, my physician colleagues will fully showcase the wonderful medical skills I have been privileged to witness. 

Along with this, we are excited to help deepen the skill pool of pre-hospital workers. As we finish our data collection with our time at the 911 call center, we are seeing areas where we know what we are doing can have huge benefits. By helping to organize and standardize the system into an MIVT format, we believe the standard of care can continue trending in an even more positive direction. On Monday we begin the training!

Final draft of the implementation card we will hand out next week, printed and laminated by the government

As always, I like to update on the FUN we're having down here. Cuenca is truly a hidden gem and keeps surprising us with more to do in and around it each day.

First Bowling Championship between LATE and VCU. We were proud to take home the trophy on the last roll.

Our FAVORITE yogurt cabin out in what we call the "Swiss Andes" surrounding Cuenca

The Chorro de Giron, thanks Caro for the great adventure!

Ingapirca, the largest Incan ruins in Ecuador, 2 hours outside of Cuenca

Am I at NASA?

At the front of the room, there’s a giant screen in place of a wall. This screen is divided into 16 frames, each with live video. Facing this screen are rows of desks and computers, each staffed by an operator, chatting away on a headset. The room is humming with the buzz of individual conversations.

Am I at NASA?

Nope, this is the the ECU911 Center of Cuenca. The room is filled with dispatchers from all parts of the city’s emergency personnel – policemen, firefighters, paramedics. The police are here monitoring live feed of the streets (from the 319 cameras installed throughout the city!), making sure that the city is safe. There are city doctors here to answer calls and offer direct medical advice to the EMTs.

After jumping through a lot of hoops, we got the necessary clearances and on our fifth time at ECU 911, we were finally allowed to go in. We were really excited to finally be able to begin data collection at ECU 911, the last leg of the project.

Listening to the radio is difficult. Imagine a staticy voice…talking in radio lingo…in a foreign language. But, luckily they take notes on all parts of the calls before entering it into the computer. We then go through their call with our checklists, making note of what is reported to the hospital from the ambulances and what is not.

Everyone there is incredibly friendly, and more than willing to answer our numerous questions. All of the agencies are right next to each other: Cruz Roja, IESS, MSP, Bomberos. When there were no calls coming in, we got a chance to chat to the dispatchers and get to know more about their organizations. They fielded questions on everything: training protocols, entry into the agency, dispatch regulations, etc.



I'm not allowed to bring my phone in (security and all that), but I was able to snag this photo off of google. (Thanks http://www.nuestraseguridad.gob.ec!)

A Mountainous Ambulance Ride-Along, Ecuadorian Style

There is nothing quite like a Friday night in the emergency department at the regional hospital in Cuenca. The previous Friday, prisoners streamed in throughout the evening after eating bolts and screws—I guess that is one way to get out of the high-security prison. Well, this last Friday did not disappoint either. It actually started off pretty slow, but soon picked up as the night drew on. As the ER was getting pretty crowded, I volunteered to ride along with the MSP Ambulance stationed at the hospital to take a researcher out of the ER. Essentially, that meant I sat outside the ER watching for incoming ambulances and working on Spanish vocabulary until the ambulance got a call. I was looking over “gordo/flaco” and “blando/duro” when Leonardo rushed over to me and said they just received a call. He asked if I had a jacket because we were heading up to Cajas, where it gets quite cold even in the day. I replied in my broken Spanish, “no, pero listo...soy de Alaska.” Leonardo, Victor and I jumped into the new Mercedes Sprinter and were off.

New Mercedes Sprinters are commonly used by MSP throughout Ecuador 

Unlike in the US, MSP’s ambulances usually go out with a doctor and a paramedic on board (based on the European model). Victor, our fearless paramedic, drove us through Cuenca in record time, flying within inches of other vehicles. Victor and Leonardo (the doctor) had clearly spent a good amount of time together and worked well as a team in preparation for the call.  Victor sped as Leonardo prepped the IV. As we cruised up the mountain pass, Leonardo explained to me that a truck had flipped with four people inside and that the Red Cross and firefighters were also sending ambulances to the site.

To give you some context, Cuenca sits in the Andes at 8,200 feet above sea level, whereas the accident occurred on a mountain road in Cajas National Park at 12,200 feet above sea level.

This picture was taken during our first week when we went hiking in Cajas. In the background there is a windy road, and the accident took place just at the end of the road on the left side of the picture.

My view on the ride up the mountain.

Thanks to Victor’s driving we were the first ambulance to the scene (the firefighters already had the road blocked off), and with a doctor on board, we had the responsibility to take care of the highest priority patient. A large group of people crowded over the 4 wounded, who had been placed on the side of a hill next to the flipped truck, and let Leonardo through as he rushed in to perform his initial assessment. By the time we had patient on the body board with the cervical collar placed, most of the other ambulances had taken off with their patients. Once inside the ambulance, Leonardo performed a more in-depth assessment. The patient felt pain in his chest, but Leonardo could not hear any signs of fluid or air in the lungs. His vitals signs were in the normal range, and he appeared relatively stable, although in pain. Leonardo placed the IV, and we were off again to the hospital, although a little slower this time.

Crowded scene just after arrival

The crowd let emergency workers through. Red Cross in the back 

Leonardo's initial assessment, and Red Cross about to transfer a patient

Red Cross leaving the scene

We eventually pulled up to the emergency department, and as we swung open the back doors of the Mercedes, we were greeted by a crowd of people—the patient’s family, who had been eagerly awaiting his arrival. One of them broke into tears after seeing his condition. With all the rushing, I found our arrival quite ironic. We wheeled the patient into the ER and everything seemed to just slow down. Leonardo presented the patient to three different doctors over a period of 20 minutes, the time it took to transfer the patient from the gurney to a bed (they had to wait until another body board could be found in the hospital). It should be noted that the patient seemed to be in a stable condition, and Leonardo even had him smiling before the hospital’s back board could be found. Still, I found it interesting that the pre-hospital care was pretty efficient in this case, and it was not until we got to the hospital that things seemed to slow down (an interesting observation in the context of our research). Overall, it was a heart-pumping learning experience, and I am grateful to VCU and our partners in Cuenca for the opportunity to study medicine in this way.

"It just happened..."

A patient was sitting in the ER grasping his hand, trying to stem the oozing bleeding with some drenched gauze. As the gauze was completely saturated, it didn’t do much and the ground was splattered in blood. He had been hanging out with some friends and somehow “it just happened”. A knife had sliced through his 3rd, 4th, and 5th finger. After waiting an hour for an ambulance, he ended up in the ER to await some sutures.

The intern tapped each finger, checking the function and movement. Both the intern and the patient looked surprised, when they got to the fourth finger, and… nothing happened. While I couldn’t see any tendon beneath, I could only assume that the knife wound had knicked it (flexor digitalis longus! Thank you, anatomy class). After the intern consulted with another doctor, they decided to go ahead and suture it together and then have him return for a consult.

I’ve seen a lot of blood and accidents after working as an EMT, but it was so hard for me to watch as the patient got prepped for sutures. The intern gave him a dose of Ketorolac into his arm before beginning. But, it didn’t seem to do much. As we started on his fingers, we cleaned the wounds with alcohol to better visualize it. He was being physically restrained by his friend as he groaned through gritted teeth. Every single time we touched his fingers, he was sent into more pain. I was getting really worried because I didn’t know if he would get any more anesthesia (And I think he was too). Fortunately, he did. Whoever invented local lidocaine is a genius. He went from writhing in pain to waiting in boredom for us to finish the sutures.

“Secalo.” Dry it. “Cortalo.” Cut it. It felt like I was back at my own job as a medical assistant to surgeries at the Family Dermatology of Albemarle. Déjà vu. Different country, but the same routine. Sterile gloves on, cut with the blunt side, nonexistent tails for the deep sutures, and short tails for the external sutures.