Virginia College of Emergency Physicians Post

Thanks VACEP for highlighting us! VACEP is a collection of the finest emergency physicians in the state of Virginia and were very kind to put us front and center on their newsletter.
http://multibriefs.com/briefs/VACEP/VACEP082516.php

Making More News

The project continues slowly but surely, even if our updates do not. The LATE students we worked with are currently doing the post-implementation workup to check on the efficacy of the training program we designed and participated in. The Ministery of Public Health for Ecuador is also planning to spread the training beyond the 350 emergency employees from Cuenca into the surrounding pueblos sometime in September. It has been an honor to work with such dedicated and passionate people! As more numbers and information flow in, we will be sure to let you know more results. For now we are in the write-up stage of the project and trying to survive the dog days of medical school.

We also made some more headlines! Check out http://news.vcu.edu/health/Medical_students_travel_to_Ecuador_to_help_with_emergent_care

Experience Summary Post - Mark

I’m in the firefighter training facility in Cuenca, Ecuador, standing in front of 38 emergency system personnel from the city. Over the next week, the pre-hospital communication course my team researched and designed will be taught to all 350 EMS workers from Ecuador’s third largest city with the stamp and seal of their Ministry of Public Health. The training will be led out by...well, me, a foreign medical student, with thankfully an Ecuadorean physician and my student team members right behind me. As I try to gather my thoughts in a second language on a topic I knew nothing of 10 months ago, I have to think - How did I ever end up here?

Growing up, I was privileged to assist on four mission trips to South America, where I became fluent in Spanish, learned to love Latino culture, and found my life calling in global health. Entering medical school at Virginia Commonwealth University, I began looking for experiences in third-world medicine deeper than what a typical trip offers.

The team in Cuenca's main square

When the opportunity arose to help augment a trauma system project initiated in Ecuador by Dr. Sudha Jayaraman, I immediately jumped aboard, eventually convincing fellow first year students Jeremy Carter and Elissa Trieu to join me. Our team’s ability to work together seamlessly while balancing strengths and weaknesses proved vital as numerous inherent trials of international research existed throughout the project. Although mentorship was available when needed, we were often left to ourselves to decide research details. The autonomy proved both enjoyable and, sometimes, frustrating, but gave us an enriching learning experience.

In order to prepare myself to perform the project, I did my best as a first year medical student to study up on the MIVT checklist (Mechanism of Injury, Suspected Injuries, Vital Signs, and Treatment/Time of Arrival, commonly used in United States EMS presentations) we would be utilizing and shadow every part of the top-ranked Richmond trauma system. Experiences included the trauma bay alongside Dr. Jayaraman, hospital communications center, ambulances ride-alongs, and even life flight transports.

The team at Ingapirca Incan ruins

As we read through the previous research, communication presented a key issue in the Cuenca pre-hospital emergency care system. We decided to design an objective study to assess the quality of information passed at three crucial points in the pre-hospital communication tree, based off a form of the MIVT checklist approved by the Cuencan physicians. Using a yes/no checklist, researchers would be at the three stations and confirm whether or not specific information was passed during the verbal presentations.

No matter how much we prepared beforehand, our team could never have done enough to deserve the life-changing experience that was before us. We were privileged to work with Dr. Juan Carlos Salamea, Ecuador’s chief surgeon, Dr. Alberto Martinez, a wonderful down-to-earth emergency physician, and four energetic medical students from the Liga Academica de Trauma Ecuador, or LATE. Their incredible reception of us, along with that of our host family, to the hidden gem of Cuenca cannot be overstated. Beyond the day excursions, food, and cultural lessons, however, was the real reason we came: to improve the existing pre-hospital communications through research.

Beautiful Cuenca

Plans had changed by the time we arrived, however. Not only would we to collect our data within a two week frame, but we were to then present our findings and suggest improvements at a city-wide conference for all emergency personnel. This would be followed by a comparison post-implementation study. We worked diligently with the LATE students to be ready for the new lofty assignment we had been given.

Data collection proved an ever changing beast. Waiting for ambulances at the hospital was taxing, as we averaged about one patient every two hours at that station. Five times we went to the 911 call center hoping to enter; five times we were turned away, needing a different authority’s signature each time before we were allowed to enter on the sixth attempt. However, the EMS personnel were all extremely welcoming and receptive to the work we were doing, making every pain worth it in the process. When the presentation day came, we knew quite a few in the audience, and there was mutual respect and trust for one another in our collaborative work.

Teaching with Dr. Martinez

How did we become qualified to train? We participated in the process. We asked questions. We diligently collected the data and presented our findings. We communicated complaints from those within the system and suggested improvement processes. We presented towards observed specific needs, such as having a Glasgow scoring role play to correct some misconceptions. And above all, we built relationships with people who helped move the project forward that I expect to last a lifetime.

Our "Ministry Approved" card

At the course’s conclusion, an MIVT information card our team designed was given to all 350 conference attendees. The Ecuador Ministry of Public Health gave a literal stamp of approval to the card, with a mandate for system workers to carry it with them at all times. I saw the EMS team’s desire for change exemplified by a 30 year veteran firefighter being the first one to eagerly accept a card and immediately keep it next to his name badge. Each course we taught brought a new wave of incredibly receptive and inquisitive team members ready to listen and improve.

What will come from this experience? I know I have been changed beyond the research opportunity I initially sought, as I am now looking into career options in global health. But this project quickly moved beyond me and my team, and is continuing to grow into something bigger. The Ecuadorean government has requested our presentation be shared with the emergency personnel of the villages surrounding Cuenca, with plans for an annual refresher course in the works. Our updated findings will be shared with physicians in the hospital in hopes they make the necessary changes as well. And my greatest hope is to return to Ecuador someday and see our card in use during a perfect MIVT presentation, our research findings helping to save the life of yet another patient passing through the Cuenca trauma system, the system our labors helped change. 

Mark is a second year medical student at Virginia Commonwealth University and is originally from Logan, Utah. Medical and service experiences in Central and South America have made him fluent in Spanish and shaped his current interests in emergency care and global health systems. When he can get away from the books, he is also an active outdoors man and is the founder of the Medical Student Athletic Club at VCU. He can be reached at hopkinsm2@vcu.edu for further details on the project.

Training, the Beginning of Change (Ojalá)

Finally, after hours of waiting for ambulances to collect information, getting sick, struggling through Spanish, multiple attempts with the Ministry of Health to get the correct permission, and months of trying to make the correct contacts, we were able to see some of the payoffs for our research. I am not saying our research is done by any means, but on Monday, we taught our first class of EMS professionals...and it felt great. We were actually a little taken back by how eager most of them seemed to be at the training. As a seasoned paramedic told us, he had never previously received instruction regarding standardized communication when transferring a patient to the hospital. In fact, many people we spoke to during the training commented that they wished for more training opportunities like this. Looking back on the mandatory trainings I have attended (e.g. HIPAA), I have never really been eager to go, let alone ask for more. I was impressed by their general interest and passion for their field. For the first time in Ecuador, it finally felt like what we were doing could make a positive, long-lasting impact. It might actually stick.

For the next week, we (Dr. Martinez, Dr. Salamea, LATE students, and VCU students) taught two hour-long sessions a day about MIVT, while the class (about 35 people in each) stayed for another two hours to learn about proper radio protocol, and how to organize a trauma scene. As the Ministry of Health posted on their Facebook page, the training consisted of "337 participants of the MSP, Red Cross, Firemen, IESS and Sis-ECU 911." Essentially, the training included all of the pre-hospital providers in the third largest city, and medical Mecca, of Ecuador. Our presentation included the pathway of communication in the Ecuadorian pre-hospital system, stressed the importance of their role in transferring the patient using MIVT, presented our data from the previous weeks, ran through assigning a Glasgow score, provided a real example of poor communication, and finished with an exercise that allowed the class to use their newly approved MIVT cards to present to a partner as if at the hospital.

MIVT, or IMLST in Spanish, approved by the Ecuadorian Ministry of Health. We designed the card based on MIVT protocol and information requested by receiving hospitals as determined by a previous ITSDP project. The card was designed to fit in with their ID cards--to be readily available. 

The class using their new MIVT cards to work through the exercise.

Now for a bit for the pessimist inside me. I have been wary of that "special summer project" where that ambitious, naive person travels to a developing nation to build a well for a community in need, when in a year, the machinery breaks and the project is rendered useless. The person leaves the village that year with some amazing photos, a fun experience, but in the end, did nothing to help the community in the long-run. That is exactly how I did NOT want this project to go. Working with Dr. Martinez and the LATE students has calmed that fear regarding this project. Pepe, Emmy, Caro and Fernando, the LATE students, taught so well and have proved their commitment to the project (even during their finals). Dr. Martinez was incredible. He drove home many of the points as we taught, and with years of experience with emergency medicine, he related well with the EMS personnel. Some doctors in South America (or anywhere for that matter) may come off at times as haughty and hard to work with, but he was just the opposite of that. His humble character allowed for open discussion, yet commanded respect from the listeners. It was clear that he is motivated to improve his community...even without proper compensation for his efforts (he is not getting any special bonuses for helping with the research and training). On the other hand, it appeared that the majority of the classes truly appreciated the training and took it seriously. I am sure more training will be due in the future, but I feel it is a great start for change. I think the future of this work is in good hands. 

Caro and Emmy introducing MIVT.

 Instruction by Dr. Martinez with Mark and Pepe. 

As my travels throughout the world have taught, you can find people everywhere that are intelligent, competent, and motivated to improve their own communities. I am grateful for the people of Cuenca for allowing me to experience their health system first-hand, for the many lessons learned, for the friendships made, and for the hope that my short time there performing this research may have lasting implications for good (even if it was just a small mark). 

I will never forget the ambulance ride-along with Leonardo and Victor to the "top" of the Andes. It was great to run into many familiar faces at the training. 

Implementation Project Video from Cuencan Government

We made the news in Cuenca! Check out this PR bit from the Ministry of Public Health, the government branch in charge of Ecuador's free healthcare system, on what we were helping them to accomplish. Training went well and the project will continue now into the post study process. More updates and thoughts on training will be posted soon.

                          Leonardo and Victor, two of our favorite ambulance ride-along workers. Some abulances have doctors, such as Leo, on board.

Teaching with Dr. Alberto Martinez, our Ecuadorean mentor, who is just incredible. Here he is patiently answering some of many complaints ambulance personnel brought up about the system during the training

Jeremy as the patient for our Glasgow training

We were pleased with how ready and willing to learn everyone was in the training

The training team with the Ministry of Public Health representatives

The students we were privileged to work with and now miss dearly

Ministry Approved

Also, a quick quote from the World Health Organization on communication in a pre-hospital setting: "Necessary components of planning of systems for trauma management include communication and transport. Communication takes into account the radio communication between EMS units and receiving hospitals. Prior notification by such radio communication allows trauma team activation and preparation for immediate care of severely injured patients upon arrival."
http://apps.who.int/iris/bitstream/10665/42565/1/9241546409_eng.pdf 

Adios data collection, hello training

With the data collection behind us, the second leg of our project consists of the training class. This three hour class is broken into three segments: 1) MIVT 2) Radio communication 3) Scene Management. And we're responsible for the first part. (To read up more about this training - go to http://cuandoencuenca.blogspot.com/2016/07/you-want-us-to-do-what.html) Two classes a day, five days this week. This equals ten classes that'll train the entire EMS personnel of Cuenca. Ready..set...go!

Everyone was really receptive and interested in the material, but more to come soon about the classes!

Caro, Mark, and Jeremy all fired up for the first day of Training

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.

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!