Valantina is the granddaughter of my host family in Riobamaba.  The family is middle class and well educated, both parents having attended university.  As is common in Ecuador, Valantina’s parents started having children very young and continue living with their parents.  Before the recent death of my host mother’s mother, four generations had lived in the house.  Valantina is 9 months old and the delight of the entire family.  As you will note in the pictures she is generally healthy and adorable.  There are some things that her family does that help her grow and stay healthy.  Though her mother is in college full time, Valantina has never received formula.  Her mother frequently breastfeeds at the table or in public places.  This is common practice in this provincial capital and during the Easter parade, there were women openly feeding their children as they marched through downtown, an unlikely sight in the U.S.  After I moved to Cuenca I noticed that more babies were drinking formula from bottles.  Multiple people explained that this as a consequence of wealth.  Cuenca is more affluent then Riobamba and formula is considered proof of economic security, an unhealthy trend.  I was fascinated by these changes because they seemed opposite to what I have observed in the U.S. where it is often well educated, more privileged women who tend to have the control over their lives that allows them to breastfeed. 

I delivered a baby today. Via Cesarean section. And an intern taught me how. Three remarkable statements to be made by a General Surgery resident about to begin her Chief year.

I am finishing my fourth clinical year in General Surgery, and feel as though I have had remarkable training thus far- both in its depth, breadth and quality. Vanderbilt is a wonderful place to train as a surgeon. I am about to begin my Chief year, where I should be honing my skills and functioning as a junior attending. And yet here I was, three days into my stay in Kijabe, learning a brand-new operation that I’ve never seen, much less been a part of, from someone who is 6 weeks into his intern year. How humbling, how awesome.  What a reminder that every day is another opportunity to learn, to grow, to be stretched a bit more. I have already been amazed at the interns with whom I have had the opportunity to work here in Kenya. They are eager, they are confident, and they are desperately wanting to learn everything that they can from me, so that they can be better clinicians.  I have already enjoyed our interactions- as we both have so much to teach one another- mine from more years of clinical experience, and them from their familiarity with disease processes and presentations not commonly seen back home. I am eager to experience the many more opportunities that I will have to work side by side these amazing Kenyan trainees in the coming weeks.  

The hospital has a well respected neonatal intensive care unit as well at both inpatient and outpatient services for women and children. One case in particular stuck with me. A woman came in after a failed home delivery. She had delivered her first 6 children at home but subsequently lost 2 of them to respiratory illness within the first 2 months of life. She had been laboring since the day before and kept saying, ‘I can’t, I can’t’. She knew something was wrong and that this did not feel like her other deliveries.
I spent one week at a Sub-Centro de Salud (public health clinic) in the town of E. Valle, about a 30 minute bus ride from Cuenca. The town is quite small but the catchment area includes a large number of families working small plots of land on steep slopes. The clinic itself is new and clean. It houses three general practitioners, one dentist, a pharmacy, a pediatrician, psychologist, vaccination center, and room for x-rays and ultrasound. In an office there is a map of all the households, their inhabitants and risk factors.
I was privileged to work in many different settings during my time in Ecuador giving me a wide range of exposures. First of all, there is private versus public medical care. The perception among those that seek care in the private hospitals is that they are receiving a superior service in exchange for paying for services that are free elsewhere. In some ways this is true. However, in the public hospitals international standards of care were followed.

Truck

My first day with the Cinterandes Foundation we left for a trip to Palmer.  The large truck with an operating room in the back had left the day before and we traveled in a small vehicle.  This trip was my first time out of the Andes since my arrival a month earlier.  We drove the Cajas National park where llamas run down the middle of the highway and alpine lakes dot the landscape before we began the decent; the humidity and heat increasing and the vegetation changing from alpine to tropical with every turn of the road.  The houses also changed from concrete Spanish houses to wood houses on stilts with hammocks on the porches.  

 Palmer is a small pueblo of less than 2000 people on the Pacific Ocean and most of the people there are considered very poor by Ecuadorian standards.  There is a public health clinic run by a German born nurse who finds cases appropriate for these trips and pre-screens the patients so that when we arrived all that was to be done was review lab results, EKGs, and perform quick physical exams.  

 Two patients were turned away because of fever and one because of irregular heart rate.  The patients need to be carefully selected so that there are minimal complications with recovery because the PACU consists of cots in the clinic and the team leaves at the end of the week.  Dr. Rodas calls all patients to insure that they are recovering well, but this system works best when there are minimal complications.  Sometimes the surgeons travel with a family physician who sees patients while they operate.  However on this trip the team included Dr. Rodas and Dr. Sacoto, two well experienced surgeons.  

 Dr. Rodas founded Cinterandes because he felt that Ecuadorian doctors could help their population just as traveling Americans could.  He was inspired by the ship Hope and trained in the US but was born and raised in Ecuador.  Dr. Sacoto, the other surgeon is the dean of a medical school in Cuenca.  During the ride to Palmer he and I had a long conversation about evidence based medicine and the pedagogy of medicine.  There was also Dr. Anita the anesthesiologist and executive director of the organization.  Her role on the trip made me think about anesthesia in a whole new way.  She not only anesthetized patients from 5-76 years old and with everything from local nerve blocks to general anesthesia but also serves as an extra set of unsterilized hands in surgery helping with everything from preparing the patient (cleaning) to helping set up the laparoscopic equipment.  

 In Ecuador anesthesiologists are at a premium.  Dr. Cruz, the pediatrician I worked with in Riobamba is trained as a surgeon but works as a generalist because there is no anesthesiologist at the children’s hospital.  While working with the ob/gyn and head of the department in the public hospital in Riobamba, we had to wait two hours for an anesthesiologist to arrive so that he could operate. In addition, Dr. Anita is involved in primary care, coordinating rural rotations for medical students.  

 The final physician was Dr. Valasco who, like many physicians in Ecuador, is working as a physician before residency and after his year of rural service. He serves as the scrub tech but also does much of the pre- and post-operative care.  

 Like the physicians, the two other staff members had multiple jobs.  Freddy knows where absolutely everything is on the tightly packed truck and throughout all the surgeries the doctors often shouted, “Freeeeeedy” and he would appear from nowhere and supply the necessary item.

 The final members of the team were us 6 American medical students (there are usually also Ecuadorian students but they had final exams). We assisted in all surgeries and helped with pre- and post-operative care.  

 There seems to be 2 purposes to these trips.  First and foremost, the foundation truly believes that it is far more humane to provide surgeries, for carefully selected patients, close to their homes so that they are spared the expense of travel and the trauma of time away from their families.  Many of our patients needed these surgeries and would not have received them without this foundation.

 But students, both foreign and Ecuadorian, also play a role.  Not only do we bring labor, supplies, and funds to the organization, but the team of doctors all clearly enjoy teaching and explicitly encourage students to learn how to provide humanitarian medicine (for example instructing us on how to tie knots so as to spare suture).  It is a symbiotic relationship in which the students gain important skills and the team gains extra hands to help with the work.

 The surgeries performed were hernia repairs, lipoma removals (lipomas are benign tumors that can be disfiguring and painful), and lots of cholystestectomies.  Cholystestectomies are common here, not only because of the frequent occurrence of gallbladder disease, but also because gastric cancer is common here (more common than colon cancer in the Andean region).  In fact, endoscopy of stomachs rather then colons are the preventative tests of choice here and choystestectomies for symptomatic patients are considered part of prevention.  

 We worked for 3 days operating from 8 in the morning until long after dark and then rounding on patients recuperating in the clinic.  Many of surgeries were laproscopic and, save for the fact that the drapes and gowns are cotton rather then disposable paper and the conversations being in Spanish, you would never know you were outside the U.S., let alone in the back of a truck.

 It was a privilege to work with physicians helping their own people in this unique and creative way.  The Cinterandes team is traveling to the Sudan this year to help establish a similar truck there.  Hopefully the idea will catch on because it is a great way to utilize urban specialists to help poor rural populations without the need for expensive infrastructure development.

Truck 2RPfaff op room 3

Whenever I’ve heard people reflect about their international medical experiences (especially among my colleagues who have worked here in Guyana), there tends to be a few common themes that emerge. There are statements about the gratitude of the local population, and their resilience in the face of adversity in nearly every aspect of their lives. They discuss the lack of resources available; how the hospitals/clinics can lack the most basic of amenities (gloves, bandages, water), or how few and far between medical practitioners are located. Universally, people say the experiences have changed them at their core; they now have a greater appreciation for the resources/opportunities available back in the US, and will continue to work to improve the plight of those less fortunate.

Looking back upon my experiences here in Guyana, my colleagues could not have been more right. Despite significant influence from first world nations, life in Guyana is hard and often unforgiving. Conditions that seem routine back home can often prove fatal down here, and both the medical providers and patients are well aware of this fact. This doesn’t stop either of them, however, from fighting as hard as they can, and utilizing their resources as fully as possible. I feel blessed to have had many opportunities to help care for patients here, and the experience has without question pushed me to higher places as both a physician and a person.

Above all else, my time here in Guyana has left me motivated to come back and do more. The potential that exists amongst the medical community, especially in Emergency Medicine, is quite palpable, and there seems to be a feeling that the tipping point can soon be reached. Once that happens, it could ripple through the rest of Guyanese society and hopefully produce successes and advancements that might have once seemed impossible. Of course, it’s not a guarantee, and many obstacles need to be dealt with. However, there is genuine hope, and that’s often the most important first step. 

Sometimes the most difficult parts of a job produce the situations you learn the most from. Often doctors will remember their most challenging patients for the rest of their lives and rarely forget what they’ve learned through those interactions. Working at Georgetown public hospital has afforded me a wealth of opportunities such as these in my short time here. 

Near the end of a shift one day I saw a patient with chest pain, a thin, uncomfortable-appearing woman in her 50’s. When asked where her pain was she did the classic motion of waving her hand over her entire chest and abdomen, attempting to help me pinpoint where she was hurting. I started with x rays, an ecg and blood tests but unfortunately these would take quite a long time during this busy day. Hoping for faster results, I looked for the ultrasound machine to assist in my work up. After a long search and a battle to keep the battery on, we had it at the bedside. Looking at her heart, lungs, kidneys, liver, and great vessels with the ultrasound machine gave me a wealth of information. I could see she had fluid around her heart and one of her lungs. That provided me a clear start that ended up guiding much of my treatment for her. Although getting the ultrasound, using the machine, interpreting the US (no Radiology to help interpret the scans) were all much more difficult than doing the same would have been in the United States, I can honestly say I learned even more from the process than I would have in my home institution. The difficulty in getting the machine caused me to use it as a precious resource, getting every possible use out of it that I could for that patient. Not having Radiology back up or easily obtainable diagnostic tests caused me to fully scrutinize every image, think outside the box, focus on physical exam clues, and tested my confidence in my own ability to obtain and interpret ultrasound findings. On top of all that, I got to teach a group of residents and nurses aspects and uses of ultrasound that they had never seen before. The experience highlighted learning opportunities I take for granted working in the United States and helped me develop my own diagnostic abilities.     

Andrew Pfeffer Pic 2

Whenever I’ve heard people reflect about their international medical experiences (especially amongst my colleagues who have worked here in Guyana), there tends to be a few common themes that emerge. There are statements about the gratitude of the local population, and their resilience in the face of adversity in nearly every aspect of their lives. They discuss the lack of resources available; how the hospitals/clinics can lack the most basic of amenities (gloves, bandages, water…), or how few and far between medical practitioners are located. Universally, people say the experiences have changed them at their core; they now have a greater appreciation for the resources/opportunities available back in the US, and will continue to work to improve the plight of those less fortunate. 

Looking back upon my experiences here in Guyana, my colleagues could not have been more right. Despite significant influence from 1st world nations, life in Guyana is hard and often unforgiving. Conditions that seem routine back home can often prove fatal down here, and both the medical providers and patients are well aware of this fact. This doesn’t stop either of them, however, from fighting as hard as they can, and utilizing their resources as fully as possible. I feel blessed to have had many opportunities to help care for patients here, and the experience has without question pushed me to higher places as both a physician and a person.

Above all else, my time here in Guyana has left me motivated to come back and do more. The potential that exists amongst the medical community, especially in Emergency Medicine, is quite palpable, and there seems to be a feeling that the tipping point can soon be reached. Once that happens, it could ripple through the rest of Guyanese society and hopefully produce successes and advancements that might have once seemed impossible. Of course, it’s not a guarantee, and many obstacles need to be dealt with. However, there is genuine hope, and that’s often the most important first step. 

One of the best things about healthcare delivery in Guyana is that it is nationalized.  Care is free and available to every citizen.  It is financed and managed through the Ministry of Health working together with regional and local government. There is an independent private sector.   However, despite a national health system, there are several gaps in the delivery of health care in Guyana.

Chronic diseases, such are hypertension, diabetes and heart disease, are becoming more prevalent in Guyana and currently there is not an infrastructure in place to help manage this growing problem.  Patients are presenting to the emergency department at advanced stages at which time there may not be great treatment options available.    Unfortunately the regional health center, which would ideally be the place for primary care, is not very equipped. There is usually just one physician available to staff a large local population and he/she may not be well trained to manage chronic disease.  The availability of equipment such as blood pressure cuffs, glucometers, monofilaments, debridement tools for diabetic ulcers are often in limited supply. Lab testing and monitoring are usually not available.  The idea of routine screening and preventative medicine is nonexistent.  Ancillary staff, if available, is also not well trained. 

While most patients living along the coast have access to some sort of health care, whether through regional health centers or the local emergency department, those who live in the interior have little to no access.  This is largely because of the sparse population and difficult terrain. The population comprises mostly of indigenous people and miners - in emergency situations, they travel for days to the capital to receive care.

In Guyana, there is very little support for persons with mental health disorders or substance abuse.  During my short time in Guyana, there were more than a handful of persons presenting with suicide attempt, often with paraquat, a freely available but deadly herbicide.  At a public health level, there needs to be better regulation of who has access to these poisons as this is an easily preventable cause of morbidity and mortality.   There is poor education about mental illness among the population as well as among providers.  If a patient survives a suicide attempt, he/she is discharged from the hospital without any resources or treatment to address with underlying mental illness.  Substance abuse, specifically alcohol, is never addressed.  Training providers as well as the development of a psychiatric unit or treatment center will be a small step to help address this growing problem. 

One of the largest challenges to health care delivery in Guyana is the lack of an integrated health information system.  Medical records are completely on paper and patients’ charts do not go with them throughout their contact with the medical field.  The medical record is not used to support decision making.  For example, if a patient presents to the ED with hypertensive emergency, a new chart is made up for the admission.  Even though the same patient presented a week prior with the same issue, the record is not automatically included and there is no way to use information about their previous treatment to guide treatment decisions now.  In addition, the contents that make up the medical record are sometimes sporadic and often incomplete.

There are many areas that need to be built up for the health care system in Guyana to become what it needs to be.  There needs to be programs in place for advance training of physicians and compensation and work plans that keep these well trained physicians interested in staying in Guyana. Local health centers need to become the first line for screening and management of chronic diseases.  Also, within the public health sector education programs need to be developed that teaches local population about disease, mental illness and a healthy lifestyle.

In Guyana, there appears to be a commitment by the government to improve the overall healthcare delivery system.  With the monetary support and partnership with many foreign agencies, Guyana is slowly on its way to delivering the care its people need.

 

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