I took my first weekend of call this past weekend. As I was checking on a patient Sunday evening, I was informed by my junior resident that there was a “mass casualty” bus accident in a nearby town, and the police had called to say they were bringing a number of victims to Kijabe Hospital. No one knew any additional details, and as I arrived in the Casualty unit (Emergency Department), a tour-bus size vehicle pulled through the front gate. Within minutes, injured patients began being rapidly unloaded. As the most senior resident present, I was in charge of triaging, organizing resuscitations and directing patient care until an attending arrived. We very quickly identified several patients needing immediate attention, and moved quickly to stabilize them.
One of the great benefits of spending time in a place like Kijabe is the opportunity to “cross train”. I am a general surgery resident. But this week, I have learned a bit about being a urologist, an otolaryngologist, and an obstetrician.
Being diagnosed with a malignancy in Kenya is a very different thing than being diagnosed with a malignancy in the United States. CT scans and PET scans as means to evaluate for metastases are not locally available. A patient must travel to Nairobi, and frequently, these imaging studies are too expensive for most patients to afford. Furthermore, many malignancies are very advanced when they first come to the attention of a physician. Patients may delay being evaluated because of the cost, because of the distance required to get to a clinic, or because they must choose between obtaining health care and their family eating. Finally, chemotherapy and radiation therapy have limited availability. At the private hospitals, the costs are prohibitive for many patients which means that the queue to access the limited government sponsored facilities is exceedingly long making access to treatment all the more difficult. As a result, all of the procedures I have done in my first week in Kenya on patients with malignancies have been palliative in nature. This is emotionally challenging for clinicians who are accustomed to being able to offer surgery for cure. Still, it is a way by which to provide improved quality of life for whatever time a patient may have left, and that is certainly valuable to both the individual and their family.
H. would probably be at the top of her class no matter where she went to medical school. Like most of the Ecuadorian medical students I have had the privilege of working with she is curious, dedicated, and focused. She attends a prestigious medical school and has had the opportunity to complete clinical rotations at some of the largest hospitals in Cuenca and Quito. Her dream is to study internal medicine.
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.
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.
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.

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