Midway Ecuador Update

Must at least muster the energy to put up a mid-rotation post. My mini-list of excuses: A constant bug draining my health, limited connectivity, even more limited time, and giant lunch after clinic + sweltering heat = nap time.

Church in Cuenca

Anyway, I’m here. Long story short: I eat papayas and croissants for breakfast. Every day we meet for gas-station coffee, which is actually the best coffee in town. We take 2 bus trips, equaling about 45 minutes to get to the clinic every day starting in our neighborhood which is pretty upscale, with its shopping plazas, fountains, palm trees, and “hired help”. Through the morning, we migrate inward, to the depths of the chaotic, dirty, loud, humid city. We stop in an unknown neighborhood, on a wet, muddy, garbage filled street. The first day we were told to “definitely not keep going down that hill”. We heed the advice every day, and assure ourselves that nobody will harm the Blue Gringo Smurfs, all cheerily walking down the middle of the street in our blue scrubs.

Fruit Stand in Cuenca

Stepping over the occasional lounging stray dog in the waiting room, we make our way every morning to our patient exam room. Here people essentially come and go all day. We stay put. People burst in during the middle of patient histories and waltz in and out during exams. We are in the beehive and the buzzing is near incomprehensible Spanish. We try to keep up with the fast pace and the maddening crowd and the strange Western-Medicine-Reflexology-Antibiotics-For-All-Slash-Don’t-Really-Examine-The-Patient type medicine that is being practiced here. Healthy, healthy kids walk out with a stack of 5 or 6 prescriptions. In the end though, the doctor is an amazing person, a staple of this community, and is bringing a great service to people in great need.

It feels good to help at this clinic, but the experience is cheapened a bit, when we return by bus to the Great Suburbs of Guayaquil and see how the Other Half lives. This is where they want us to stay, to sleep, and to eat. They want us to enjoy all that the religion of Consumerism has to offer in its great Temple (The Mall). It feels a bit like a volunteer vacation, where you snorkel for 6 days, build a house on the 7th day and go home and brag to all your friends about how you are such a worldly, compassionate philanthropist. I’m not buying it. The people that live here need to put down their Gucci and step up and take care of their own. Perhaps we should live amongst the people we are treating every day and not be blinded by fancy shiny things on the other side of the bridge every afternoon.

Oh, am I ranting? Oops. Actually everything is fine. And with all that is said above, I actually LOVE my host family. Mariana is an amazing person, a wonderful cook, a self-less mother to her own son and her (temporary) Ohioan son. I have been welcomed here like nowhere else and I will miss this home the moment I leave.

Montañitas Hangover Cure

Continuing on with the day, after the aforementioned giant mid-day meal (almuerzo), I sluggishly make my way to Spanish class from 5:30 to 7:30 every day. Homework, readings, exams, and all! Our teacher takes this class very seriously and we struggle to make it fun.

Universidad Espiritu Santo, A Campus where Iguanas and Stray Cats Mingle

A walk home from the University leads to a nightly 1 ½ - 2 hour Spanish conversation over dinner (merienda). Topics include economics, politics, health, food, travelling, current events, my rotations, Mariana’s stressful job, UFO’s……you name it. She is patient and helpful with my broken Spanish.

Watching Holanda get beat by España

Places we visited: Montanitas, home to some of the best surfing in South America, and quite the young Ecuadorian party scene. Cuenca, a town in the hills, with cobblestoned streets, markets, and a hotel with a view of the city. La Bahia, the black market in Guayaquil, where one can find fake Nikes, RayBan’s and Izod Shirts, fresh off the boat from China. More plastic crap that you don’t need than you’ve ever seen before.

Always Choose The Window Seat

After aforementioned drama, fell sound asleep on the way to El Salvador. Woke up to the sunrise and full moon....

....then thoroughly enjoyed this Costa Rican view...

....and Oregonesque greenery....

Flying into Quito is the best, however. Views of the expansive city, big banking left hand turn, huge plateau with part of the city seemingly just dropping into space, huge Volcan Pichincha towering, airport right in the middle of town. Pilot takes some sweeping turns, working his way into the city and just plops down. As in most places other than the US, the passengers erupt in applause for this and every other landing. Of them all, the Quito arrival is the most worthy of the cheers, chip

The Photo

The adventure begins before the wheels of the plane leave the ground. After running through the mental list of critical items, I had felt pretty good when Audrey dropped me off at the airport. Despite a weighty duffel bag that was threatening to cost me extra money and a horrendous traffic jam that had me glancing at the car clock every 30 seconds, I made it with an hour to take off and I had the essentials: Wallet, wristwatch, sunglasses, passport, scrubs and tennies.

The sinking feeling came quickly when I swiped the passport under the scanner and it read. “Name Does Not Match Passenger.” Count this as the first time I was disappointed to see my wife’s face. With her smile staring back at me from the passport photo, I knew I was screwed.

Not wasting anytime, I called the owner of this document to see if she wanted it back. And to get her estimate on how quickly she could drive without killing anybody. With the clock ticking, she acted calm under pressure, found her way home, sped through the yellows, looked on the internet for the shortcut to avoid the hour long traffic jam we hit the first time, grabbed the right passport and pointed it for the airport once again. With the plane leaving at 5:30, and the handoff occurring at 5:23, I thought it almost futile to sprint with my shoes untied, laptop in armpit, leaving a trail of funny looks.

The gate people saw me running and I yelled my last name to them and they replied “Run!” which I was already doing. She scanned my ticket quickly then yelled “Run!” at me again as I took off down the ramp. I flopped into seat A18 out of breath, a few new gray hairs sprouting out of my dome. I put my wristwatch on, glance at the scruffy mug on my passport and smile, thinking of the better looking photo in the wrong passport I had been holding 5 minutes ago. Once again, I couldn’t do it without her. Ecuador here I come!

I also brought the wrong camera cord, so you will have to live with wordy updates until I can figure that out...Until then, here is a generic foto de Guayaquil taken from a place I've never been, looking at a place I've heard about.

No Such Thing As Accidents

A lack of posting has not been for lack of stories, rather lack of energy. I ran into a fellow student who is doing a pediatric urology rotation and we were comparing schedules and hours. When we determined that 80+ hours a week is a bit redunkulous, he encouraged me by saying "but at least you'll always have cool stories...and I just fixed another undescended testicle."

It is true, that the trauma service keeps your inbox full of over the top scenarios that simply cannot be fabricated. Toilet scrubber impalements, hand gun accidents while holding small child, stab wounds, boats and planes crashing, brakes going out on the way to the wedding, the list goes on. While perusing Typhon, the lovely program we use to document all of our patient encounters, I came across an amazing list of actual codes used to describe various incidents. Some of the following are codes that I would not be surprised to use in the last few weeks of this rotation.

E804.3 FALL IN ON OR FROM RAILWAY TRAIN INJURING PEDAL CYCLIST
E018.0 ACTIVITIES INVOLVING PIANO PLAYING
E847 ACCIDENTS INVOLVING CABLE CARS NOT RUNNING ON RAILS
E909.8 OTHER CATACLYSMIC EARTH SURFACE MOVEMENTS AND ERUPTIONS E876.9 UNSPECIFIED MISADVENTURE DURING MEDICAL CARE
E885.1 ACCIDENTAL FALL FROM ROLLER SKATES

	E920.3	ACCIDENTS CAUSED BY KNIVES SWORDS AND DAGGERS
E965.7		ASSAULT BY LETTER BOMB
E985.7		INJURY BY PAINTBALL GUN UNDETERMINED WHETHER ACCIDENTAL OR PURPOSELY INFLICTED
E995.4		INJURY DUE TO WAR OPERATIONS BY UNINTENTIONAL DROWNING DUE TO INABILITY TO SURFACE OR OBTAIN AIR
E928.0		PROLONGED STAY IN WEIGHTLESS ENVIRONMENT

Sorry, formatting is the first skill to go........

	As my preceptor likes to say, "You can't cure Stupid."

Totem

This post comes from 2:35 AM in the Resident Lounge of a large hospital. The TV is cycling through SportsCenter reruns and the hallways are quiet. Tonight, less active bowel sounds from the belly of the beast known as the ER, a far cry from last night's fifteen traumas when I vowed to never again ride a motorcycle, step foot in a boat, or even look at an ATV. I vowed to never drink more than 2 beers, and never go outside after dark. I vowed to come to a complete stop and remove all sharp objects from my house.

Waking up at 4 in the afternoon, will shake any of the previous nights vows, so I drank 10 beers, helmetlessly hopped onto an urban ATV with loose lug nuts and road it the wrong way on a one way street all the way to the hospital, all in hopes that I might be mercifully offed, instead of having to report to duty under the supervision of my arch enemy. To avoid a breach in presumed internet anonymity, I will stop there.

In all honesty, overall, a great rotation so far. Besides the sleep deprivation and permanent location at the bottom of the Totem, things are looking up.

Evening Routine

My wife wants me to tell the truth....I watch this video before leaving for the hospital every evening.

OK

The start of week 2 has already begun....I can now navigate the maze of hallways, find the staff bathroom, and participate in the chaos of needles and paperwork of a trauma. Definitely not without a good tongue lashing by a grumpy Attending....and some snide comments by an ER nurse.

You basically are the bedpan for anybody having a rough day.

I'm OK with that. I'm letting things wash over me like an ocean wave...enveloping me for a moment but gone in a matter of seconds. I remind myself that the light is appearing at the end of that hallway. And I tell myself that It Is Better To Learn The Hard Way Than To Not Learn At All. (which surprisingly has never been quoted before).

There are other reminders that I am doing OK, relatively. Unlike my recent patients, I have not:

Been stabbed 22 times in the chest by significant other....

Fallen off my ATV after 10 beers and no helmet....

Fractured my sella turcica after a skateboard crash.....

Filled up my ostomy bag with blood 3 times before passing out.....

Gravity

First day awkwardness is present in most rotations, meeting new people, learning where to park, arriving overdressed, etc. In the trauma in-patient rotation, this is exacerbated several times over, as there are countless angled, empty hallways to navigate, hundreds of buzzing and beeping rooms, a cadre of residents, attendings, other students, trauma and ICU nurses, and various other staff who know exactly what their niche is.....while on Day 1 your role is as clear as the substance in that bedpan.

Thrown into the fire in the first few hours, I am told to go see a patient with a fever, post-op, after ORIF of L ankle fx s/p MVA. I remember my five W's, but before I can impress the PA too much, we get called to a trauma and I miss horribly on a radial ABG. Fumbly, sweaty hands amidst a buzzing room of people. Wires and bags and meds and IVs all orchestrated over this supine victim of a slipped car jack, resulting in a car landing on a chest. But the sweaty PA student can't get the ABG. The next trauma, a 4 year old girl who fell out of her 2nd story bedroom while playing with brother, has very minimal injuries but I play it safe and hang out in the corner, a little gun shy. A general surgery consult, and some hikes over to the ICU, and medical floor.....I leave the hospital completely exhausted, completely intimidated, and completely desiring to NOT work in a hospital.

Like the law of gravity that brought the car upon the man's chest and sent the girl hurtling down to her own lawn, there is a law that states that all Day 1's suck. All ABGs will be missed, and all thoughts of competence will be flushed down the toilet in the only clean staff bathroom (that you can't find). Gravity is the force of attraction that brings tangible objects down to earth (at 32 feet per second), but ego and confidence are also lowered to the ground....sometimes much quicker.

Caj Mahal

6 weeks off to complete a systematic review (a.k.a. thesis, capstone project, master's hoop, the paper, the project, the PICO, the vacation, the procrastination....)

Call it what you will, but I am thoroughly enjoying my break from khakis and business casual wear. I'm unshaven and wearing flip-flops. I can see my wife from where I am sitting.

Anyway, oh faithful readers, this blog will likely be taking a hiatus, unless I come across some really interesting paragraphs about "the off-label use of prazosin for sleep disturbances in noncombat related PTSD" and feel the urge to share.

Otherwise, check back in a few weeks for a more reader friendly topic....My trauma rotation in downtown Portland.

Recommendations, Cont.

A few more recommendations, on the lighter side:

If you lose the spacer for your 2 yo daughter’s inhaler, please call us for another one instead of spending over 1 week spraying the medicine into your own mouth then trying to blow it into your daughter’s mouth like some kind of weird backwards asthma CPR.

If your IUD mysteriously falls out, please don’t mysteriously place it in your urethra. That’s not where it goes.

Can we please get back on track after discovering that you and I went to the same high school in Ohio, albeit 20 years apart, which yes is a bit weird, but we can’t spend 15 minutes discussing it, if you also want your olecranon bursitis drained with this needle I am wielding.

When I meet you in the hospital on rounds for the first time can you please not say that you saw me in your dreams last night so we can avoid the weird creepiness of you being a 52 yo mustachioed man who lives with your mom and me just being here to listen your lungs before lunch.

4 days left of this rotation. Can I please have a 6 week break? I need it.