Last clinic week - Adolescent clinic

My fourth week of clinic was spent at Clinica de Adolescentes. I am working with Dra. Carrera and a doctor named Junior (both pediatricians) and two obstetrician students (Nancy and Maria). The adolescent clinic is located adjacent to the maternal hospital and consists of 4 large rooms with 8 beds each filled with teenage moms (any woman 18 years or younger spends her postpartum days in this area of the hospital). Starting at 8 am we round on all the newborns. I am doing newborn exams galore! Testing baby reflexes, hips, hearts, lungs, fontanelles and checking all the babies for jaundice. It is great getting so much exposure to newborns.

All of the teen moms get a session with a psychologist, gynecologist (for birth control counseling) and they have classes about motherhood. It is sad because some of the teen moms are 13. They look like babies themselves and now they have a baby. It is also sad because about 50% of the girls do not have the father of the baby in the picture. Apparently, teenage pregnancy is on the rise in Ecuador and it is fueled by the lack of sex-education in schools, the catholic influences that discourage birth control and some other cultural norms that take most, if not all, of the responsibility off of the men when a baby is born.

During rounds, if a baby looks particularly jaundiced for the number of hours old it is, Junior would get a blood sample. Then after morning rounds we would move to the outpatient clinic and see about 10-15 patients. Well-child visits or sick visits for children of teen moms.

I really liked the adolescent clinic and I am glad that it exists for all of the teen moms of Quito.

Here is Junior, Nancy and maria in the outpatient exam room. It is funny how I have not taken a single picture on any other U.S. rotation but in Ecuador I am shameless and take pictures every week. Haha. Aren't they cute?

Tonight my mom and Kari arrive and I will see them tomorrow! I can't wait. And we leave for the Galapagos on Sunday!

Out and about with Juan Carlos

Our Spanish teacher, Juan Carlos, has been introducing us to Ecuadorian food from day one. Last week we went for ceviche:

And then he invited Kibby and I to his house for cuy (roasted guinea pig). Guinea pig is a traditional Ecuadorian dish and dates back to Inca times. We were completely honored by this invitation. He lives with his mom, wife and 2 kids aged 2 and 12. He said that his mom would be making the guinea pig.

He picked us up at the Spanish school and took us by bus to his house. Before the cuy, his mother Rosa served a delicious soup that is usually eaten at holy week called Fanesca. It had a corn base with beans, tuna, hominy, fried plantains, tiny empenadas, salsa, egg, cheese and corn. It was DELICIOUS!

Kibby,me and Juan Carlos enjoying roasted guinea pig.

Here is the cuy. You can see the tiny claws. It tasted like roasted chicken. The skin was a little thicker than chicken skin. All in all a delicious meal and a fun experience too!

Week #4 IESS and the coast

I started clinic week #3 in the hospital IESS which stands for Instituto de Ecuador de Social Seguridad. This is the hospital for all citizens who get health care through their jobs. So they pay into the health care system (like Medicare) and then they get health care through the designated social seguridad hospitals. According to one of the medical students, 20% of the population is in this system. The hospital is enormous and takes up an entire city block and it took me at least 15 minutes and asking 5 security guards to find the gynecology department. The hospital is filled with people waiting in lines leading to different doors and halls all labeled with every possible specialty: oncology, cardiology, rheumatology, dermatology etc. There are clocks everywhere but none of them are set to the right time! For some reason, the whole place felt kind of communist to me. I’m not even sure what this means but it just did.

It was hard to take a picture of the entire hospital because it was so big. Here is an attempt:

Here is one of the entrances

The facilities were all very nice and were much more modern than Hospital Maternidad (public hospital). I met Dr. Salazar and he was scheduled for 3 gynecology surgeries in the morning which I watched. One hysteroscopy (looking in the uterus with a scope) and 2 diagnostic laparoscopies (looking at the reproductive organs through the abdomen).

In the afternoons I continue to have Spanish classes. Spanish is coming along. Good signs: I can talk in past tense! My mind no longer floods with Swedish/Norwegian words when I am trying to say something . I think my patient interviewing skills have gotten tons better during the past 4 weeks.

The next day Dr. Salazar had clinic. IESS has electronic medical records! He saw about 10 patients for post surgery visits, surgery consults or for regular well-woman exams much like my preceptor in California.

The week continued with more surgery, colposcopy clinic and another day of regular clinic.

This weekend, Kibby and I traveled to the coastal town of Atacames which is just south of Esmeraldas. When we exited the bus we were flooded with tropical, humid air. The town of Atacames is a beach destination for foreigners and Ecuadorians and has lots of bars lining the beach.

Here is the sunset on the night we arrived

We didn’t have the best weather. Cloudy Saturday and a little rain on sunday. But you can see that this is not deterring any of the Ecuadorians from enjoying the beach. (It was still really warm and we got pretty burned through the clouds)

Apparently Ecuadorians eat ceviche (uncooked seafood marinated in lemon juice and seasoned with onions and herbs) for breakfast on the coast! I opted for the fried fish and bolón (which I thought would be ham/bologne but turned out to be a ball of corn filled with cheese). Very delicious.


But how the Ecuadorians love to dance! On the beach, in the bars at 2 pm, into the wee hours of the morning, they were constantly dancing. Old, young it didn’t matter. It was so cute and it made me wish that my culture had more of a love for dancing.

Here is a banana and fruit shop in Atacames. We saw tons of these on the way from the bus as well.

We had a relaxing weekend on the beach, ate well and danced and even went to a karaoke bar where our biggest success was summer nights from grease followed by a backstreet boys song.

Mindo - Zip lining, Chocolate factory and a search for Toucans!

This weekend Kibby and I left Friday afternoon for the town of Mindo. Located 2 hours by bus outside of Quito in a cloud forest, Mindo is a great way to quickly escape the bustle of Quito and join a small, tourist friendly, slightly hippy town with tons to do.

Here is the main drag of Mindo.

So what is a cloud forest? I had the same question. According to wikipedia it is a tropical or sub-tropical moist forest characterized by persistent low level cloud cover usually at the canopy level. I tried multiple times to adequately capture the cloud forest but I don't feel like any of the pictures did it justice. But here are a few attempts.

We arrived and found a hostel that was very cute and homey and run by a family. We had met some other travelers on the bus so we ate and hung out with them the first night and the rest of the weekend. The second day we went on a walk into the forest and then went on a terabitha across a canyon that led to a hike that led to 7 waterfalls.

Then we went zip lining which was super fun. We got to fly through the cloud forest and try different positions on the zipline.

Regular zip lining.

Nina doing the Superman

Kibby doing the Mariposa (upside down) with our cute as a button 14 year old guide. Haha!

Then we took a tour of the chocolate factory in Mindo. It was very interesting to see how chocolate is made. Most of the chocolate that they produce in and around Mindo is made into nibs and sold to other countries for processing. They do make some bars in Mindo but only for the tourists. Here are a whole bunch of cacao beans drying.

Here are the nibs ready for shipment

Last but not least we got to try some of the chocolate products. Unsweetened chocolate with sugar and ginger syrup or crushed red peppers. They also had some chocolate bar-b-q sauce to try.

The next day we woke up at the crack of dawn to go bird watching! The dad of the family who owned the hostel we were staying at, Marcelo, is a bird watcher and he is so good at what he does! The fact that he can find these tiny birds in trees hundreds of feet away is pretty amazing. He can also imitate many bird calls which he used to lure birds closer. For any bird watchers out there, here is a list of all the birds we saw:
* White-winged tanager
* Pootoo
* Grey motmot
* Cattle Egret
* Golden tanager
* Ornate Flycatcher
* Swallow tailed kite
* Squirrel cuckoo
* Tropical Kim bird
* Yellow Rumped Tanager
* Cinnamon Becard
* Crimson Rumped Toucanet
* Yellow-Bellied Seed-Eater
* White-Shouldered Tanager
* Spotted Woodcreeper
* Red Headed Barbet
* Slated-Cap Flycatcher
* Black Headed Vulture
* Double-Toothed (or toed) Kite
* Blue Necked Tanager
* Red Bearded Parrot
* Choco Toucan
* Pale Mandible Aracari Toucan (endemic)
* Plumbeous Pigeon
* Golden-Crowned Flycatcher
* Golden-Olive Woodpecker
* Golden Headed Quetzal
* Blue-Grey Tanager
* Rufous Motmot

I was able to take some pictures using Marcelo's super-zoom-scope (this is the official name). This is the black headed vulture which I thought of as bird watching 101 because even I could see this bird with my naked eye in the tree and it didn't move very much so he was easy to take pictures of and re-locate with the binoculars.

We saw 4 different kinds of toucans including this Choco Toucan. Isn't he a pretty guy?

This is the Golden Headed Quetzal. Very bright and beautiful.

And this is a type of Motmot.

Burgeoning bird watchers!

Hospital Maternidad

Week number 2 of my clinical experience and I am working at Hospital Maternidad, one of the main birthing hospitals in Quito. They have approximately 30 births a day and they also have an emergency room for pregnant women with emergencies.

Here is a picture of the hospital

Here is the emergency entrance.

My preceptor's name is Dr. Marquez. On the first day I put on my green scrub outfit and joined the other students, residents and attendings for morning rounds. The birthing area of the hospital has 5 main large rooms and 4 smaller rooms that are used for the actual births. One large room is for all of the laboring women with complications (pre eclampsia, gestational diabetes etc.), one is for all the laboring women without complications. There are two rooms filled with women who have already given birth and then there is one room for women who have had miscarriages. There were many differences on the maternity ward compared to the United States but I think the two biggest differences were 1) All of the women are together in one room with absolutely no privacy and 2) Non of the fathers or any other family members were allowed on the floor because there simply is not enough room. Some of the birthing moms are as young as 15 and 16 and to think of being that young and all alone giving birth, it must be very scary for those girls.

Rounds are a lot like rounds at home. We move from patient to patient and one resident presents the patient, the attending checks to see how dilated they are and then the whole group of medical personnel move on the the adjacent bed. My comprehension during rounds is maybe 10%. Huge plummet in comprehension from the week before. But when I talk directly with one of the residents or students it is easier to understand.

When the patients are fully dilated and they have pushed a few times in the communal room, the residents run the gurney into one of the birthing rooms yelling "parto!" (Delivery!). At this point one OB/GYN resident and one Pediatric resident get ready to receive the baby, the mother transfers herself from one gurney to the birthing table with stirrups (exactly like in the US) and within a few pushes (or maybe more) the baby is born!

Here is one of the birthing rooms ready for a patient.

The baby is then taken to the nursery to be checked and cleaned. The pediatrician brings the baby in one more time to see the mom and then I don't think the moms see the babies until they are discharged which is a minimum of 48 hours after giving birth.

On the first day, the floor was very empty (I wouldn't know this until I saw what it normally looks like) and I actually left an hour early because there was nothing for anyone to do. On Tuesday, it was extremely busy with all of the beds touching one another and many postpartum women spilling out into the hallways.

Here is a picture of the hall. You can't see it in the picture but behind all the students sitting on the left there are a few beds lined up in the halls containing postpartum women.

On Tuesday I counted 12 women in beds and 4 women on chairs waiting for beds. It was crazy and I went to work recording vitals and hooking up fetal heart monitors and measuring the number of contractions in 10 minutes and how long they last. I watched numerous births on Tuesday too. In the labor area there was one 17 year old who was having a baby with anencephaly which is when the skull does not form over the brain. Even though abortion is normally illegal in Ecuador, having a baby with anencephaly is one indication for a legal abortion. The resident told me that the family had petitioned for the patient to not have an abortion and to go through with the labor and birth even though the baby will never survive for more than a few hours.

On Wednesday I teamed up with a first year resident named Diana and she helped me deliver a baby! I was so happy. The patient was 20 and it was her first baby and she was not happy with the fact that she was in labor. Oh, I forgot to mention, huge difference number 3 is that no one gets an epidural. Diana was seated and made a whopping episiotomy (difference #4, episiotomies are common for first time mom's at this hospital even though a pediatric resident told me they are not indicated just like in the U.S) I hovered kind of to the side of Diana and caught the baby and delivered it to the mom's belly where the pediatrician took over. Then Diana repaired the episiotomy. And there were 5 Ecuadorean medical students watching this whole scene. haha. The baby would be named Eduardo and he was pretty tiny. Only 2330 grams which is a little over 5 pounds. Diana said that the next day I could do more during a delivery!

And then, on both Thursday and Friday mornings there were no deliveries at all! I was so bummed. What are the odds? But there were other things going on and I continued to make myself useful. Friday there was an emergency postpartum hemorrhage repair which was pretty hectic and there was no OR tech so things were getting very messy and I tried to help as much as I could in my limited Spanish.

Here is a picture of me with Diana and 2 other residents.

I really loved being at hospital maternidad and did not want to leave. The first day I was a little shocked by the communal birthing and the fact that the residents and students don't have a place of their own to hang out and end up hanging out in the communal birthing area which would probably be really annoying when you are in so much labor pain and there are some young doctors laughing about their weekends. But, I quickly became used to the scene and realized that this is just the way it is in Ecuador and especially at the free hospital where people without insurance go. At Kaiser, the residents had their little area where they hung out and were able to monitor all of their patients constantly with fetal heart monitors. Hopsital Maternidad only has 2 to 3 fetal heart monitors so you need to physically be with your patients and the best way to do that is have everyone in the same room. And maybe an Ecuadorian woman or doctor would go to the United States and think it was really weird to be isolated in a room with your husband during labor. Who knows what they would think about that.

Weekend #2

This weekend we went to a famous market near Quito called Otavalo. It has been a market for hundreds of years and is one of the most important market in the Andes.
This is a major tourist attraction so there were tons of tourists. The indigenous sellers sell knitted goods like sweaters (alpaca and wool), hats, socks, finger puppets and ponchos as well as paintings, jewelery, blankets, scarves, carvings and one part of the market sells food. I was very interested and intrigued by the outfits of the indigenous people. The men wear blue or black ponchos with white shirts and hats and the women wear beautifully embroidered white shirts with ruffled sleeves, black skirts, a scarf and many gold necklaces.

Here is a picture of the woman I bought a sweater from. I was quite embarrassed to ask for a pictures but she said she didn't mind at all.

This is a picture of a couple walking by in their traditional clothing. I didn't ask them if I could take a picture.

The next day, after living in Quito for 2 weeks, I finally spent a weekend day in Quito and saw the famous and beautiful old town. First I went to a soccer game with Kibby (friend and housemate from Canada). It was El National (a Quito team) vs. Emelec (a Guayaquil team). The underdog El National won 2 to 0. And the fans were going crazy!

Then we took a walk through the old town. We walked past at least 10 churches and went into 3 of them which were all in very different styles. As we were walking around I could not stop taking pictures. Every corner we turned was another beautiful view of a hill top or a church or an Ecuadorian flag flapping in the wind. It was all breathtaking. Here are just a few of the pictures I took during our afternoon in down town Quito:

On Monday after clinic, we (me, Kibby, Ben and Abe) met up at the Trole station and caught a bus to the tiny town of Papallactas which is known for its thermal bathes. Our host mom told us it was a 1 hour bus ride from the southern bus station but this was not the case and around hour 3 on the bus I was thinking: there is no way this is going to be worth the trip. But surprisingly, it totally was. Papallactas is the cutest little town nestled in the middle of lush green mountains. As we were walking to the pools the little houses had baby chickens and dogs running through the yards. We got to the pools and they were almost deserted and we soaked for 2 hours as the fog rolled over the mountains and the steam rose from the pools. Then we were on the bus for another 3 hours going home. All in all, 8 hours of bus ride for 2 hours of pool time and totally worth it.

Cochapamba, clinic week 1

This week I started my clinical experience at the Centro de Salud – Cochapamba Sur. This is a public health clinic and all of the services provided at it are free. They have a family doctor, an obstetrician, and a nurse who gives vaccines and draws blood. My preceptor is Dra. Silvia Sancho and she is a general practitioner in family medicine (medicina familiar). She sees mostly babies and kids but also adults. To get to the clinic I take two buses which cost 25 cents per bus.

Here is a picture of me in front of the clinic.

On the first day, I did not know what my role in the clinic would be. Would it be like rotations in the US where I usually see patients, do a history and physical and then present my findings to the preceptor? It soon became apparent that this is not how it would work. First of all, the doctor’s office is also the exam room and the patients come in one after the other, calling the next patient back as they leave the office so I simply stayed in the exam room with the doctor and tried my hardest to understand the patient interactions. Over the course of 3 days I think that I went from a 50% comprehension rate to 70%. I would do basic exams before Dra. Sancho and she would point out interesting findings (umbilical hernia, atrophic vaginitis, heart murmur etc). The majority of the patients were there for toz (cough) and gripe (flu). Most of the patients coming in with these complaints left with analgesics and orders to drink many fluids and chamomile tea.
I was struck by both the similarities and the differences between family medicine in the United States and Ecuador. Many things were identical to the US like height and weight growth charts, developmental milestone questions for babies and kids (does your child know his/her colors? What words does he/she know?). Some differences that I noticed this week are:
2 brothers ages 10 and 11 who came in without a parent or guardian. This was totally fine and the exams proceeded normally. When asked if they work they both responded yes. They sell food for a few hours every weekend to make extra money for the family. It struck me that you would never think to ask a 10 year old if he worked in the United States.
Most of the patients get a lecture about how they need to gain weight as opposed to loose weight (there was one woman who got a loose weight lecture). These lectures commonly include the need to emphasize the rice course (secundo) as opposed to the soup course.
Rarely does a baby or child cry during the exam (In the US I feel like it is rare if a child doesn't cry!). I don’t know why but babies and kids are much more mellow in Ecuador in general. They just hang out and don’t make a big deal about things. You see babies everywhere (On the bus, in the market, at soccer games, at late night parades) and they are never crying.
Every child gets treated for parasites regardless if they have symptoms or not. It is one of the standard procedures for every well child check.

This is the exam room and Dra. Sancho's office

Here is the waiting room that when I arrive in the morning is completely filled with people sitting and standing against all of the walls waiting for vaccines or for blood and urine tests or for the various doctors that work here.

This is Dra. Sancho herself with one of her patients. She is wearing that heavy sweater because it would get really cold in the exam room.

Carnaval!

For the festive vacation time of Carnaval in Ecuador, I and 4 fellow travelers set out on my first weekend trip. Destination: Baños (a small town surrounded by steep mountains and an active volcano and named for its natural hot spring baths) and Ambato (one of the best places to celebrate Carnaval and known for their parades).

I traveled with everyone who was staying at Rosita’s (Nina, Kibby, Ben and Abe). Here are some highlights from the trip:

This is a view from the bridge leading from Baños.

After arriving in Baños, the first day we went on a rain forest tour in the Amazon. We went to a monkey sanctuary where the monkeys are very friendly, went on a hike to a waterfall, got a natural facial (mud straight from the ground), went canoeing and ended the tour overlooking an amazonian river hanging in a hammock.

We also took a 12 mile bike ride which took us along a canyon where we saw countless waterfalls. We hiked to 2 of them.

Part of the tradition in Ecuador for Carnaval is on the nights of Saturday, Sunday and Monday revelers fill the streets with bottles of colored foam that they spray on their friends or any passersby. This can also include water balloons and water guns. It was quite a site. We were sprayed all of the 3 nights as well as during the day while on the bike ride and even when hiking down to a rain fall (!). As we were getting a ride in a truck at the end of our bike ride we were a target for groups of kids who would hurl giant buckets of water from the sidewalk into the truck. But you can imagine the feeling of celebration on the streets when the entire country is having a water fight. I have included a picture of what these spray cans of foam look like (basically like aerosol hairspray cans). And also some people having fun at the parade with a foam fight.

After 3 nights in Baños we headed to Ambato for their famous Carnaval parades. We also saw a bull fight which is traditionally done every year for Carnaval. That is something that was culturally interesting but I never want to see again. Here is how the bull fight works: The bull runs out. 3 matador helpers have the bull charge them a few times. 2 men on horses emerge and the bull charges the side of one of the horses who is wearing armor. As they do this the man on top spears the bull in the back of the neck. 2 more men with spears stick them in the back of the bull. At this point the matador comes out, does some tricks with the bull and after a while (the bull is dying by this point because the man on the horse did the most damage) he gets his sword and finishes the bull off. the end. Then the whole sequence starts over. They were killing 6 bulls but we only stayed for 3.

But the trip was a great success and a great way to see some new parts of Ecuador. I am struck by how friendly and kind Ecuadorians are and I can't wait to do some more exploring in Quito as well as other parts of the country.

Tomorrow a new part of this experience starts as I will be going to the clinic for the first time! I am excited and nervous.