Puerto Lopez and the Earthquake

Last weekend we decided to go somewhere warmer and travel to the coast of Ecuador. As we arrived early in the morning after an all night bus ride to a big transportation hub, we made a decision between two good beach options, and opted to head an hour and a half south to the town of Puerto Lopez versus to other beach towns more north along the coast. It was a decision that we would later come to find out, might have saved our lives. And little did we know, that where we stood at the bus terminal making this last minute decision, we were in a town that 48 hours later would be flooded, with a collapsed jail and 130 escaped convicts, and a death toll of over 150 people.

We arrived a few hours later to the quaint little fishing town of Puerto Lopez. It was a sunny, perfect beach day. We picked a beautiful hostel at the end of the beach run by a Swiss and Italian couple. Our room was a beautiful wooden, one-room cabin, secluded at the back of their large property of botanical like gardens. After some much needed coffee, we set out for a walk along the beach. 

 

The next day, we headed to the only national park on the coast of Ecuador, National Park Machalilla with the secluded beach Playa de Los Friales (Friar's beach). After over an hour long, very sweaty hike through dry forest, two beaches only accessible by hiking in, and beautiful views, we arrived at the main beach. Mike was so excited to have reached the refreshing water, that he sprinted into the waves, and forgetting that a very expensive "part of him" was still attached, he lost his glasses and spent the next 7 days without being able to see much beyond a foot in front of him :( I'm happy to say that that has now been remedied.

Luckily, he was not too deterred, and we continued to enjoy the beach under our umbrella. On the beach we bumped into an acquaintance we had met briefly a few months ago in Zumbahau, an Italian Neurosurgeon working in Quito. We made plans to meet that evening back in Puerto Lopez, at sunset for drinks on the beach... Another decision that proved to be very lucky.

 

A few hours later, as planned, we were sitting on the beach, with our friend Antonio, the boys each with a beer, and me sitting in between, having just finished my strawberry daiquiri. The sun had set about 40 minutes prior, and we were silhouetted behind the last light of red-orange glow that could be seen in the distance, surrounded by the gradual darkening deep blue of the approaching night sky. As I was seated in the sand, and the ground started to move beneath me, I don't quite recall what noises I heard, but within a few seconds Mike or Antonio must have said "Terremoto," spanish for earthquake, but it took me a few seconds more to register what was going on. It felt like I was seated on a playground marry-go-round, and someone had a hand on each handle bar and was shaking it violently back and forth. The movement continued well beyond the time I realized what was happening and as I'm told, lasted for 40 seconds. The first thing out of my mouth, was (in spanish) "We are going to have a lot of medical emergencies!" As I turned to stand and face the town behind me, I could see dust raising from the buildings, and then all in one flash the power went out and everything was dark.

As we walked back toward the road and row of houses and businesses, it seemed that there was only minor structural damage, with only a few houses being reported as possibly collapsed, and no one was seemingly injured. Just startled. At first, I was immediately grateful that I had been in one of the safest places possible to endure an earthquake, outside, seated on sand, with nothing around me. I imagined the experience could have been a lot more traumatizing had I been inside a building, possibly a poorly constructed one. This sensation was short lived as murmurings around the town began as people got mixed messages about whether the epicenter was on land or at sea, and whether there was or wasn't a tsunami risk.

As I put together the idea of earthquake, beach, and tsunami, I began to feel a sense of impending doom wash over me and a desire to sprint for the hills to the side of the beach. I was on the brink of a panic attack. Mike, the calm, sensible, voice of reason and source of strength that he is, roped me back into reality with a comment to the effect of "I don't think a panic attack would be the productive thing to do right now," and realizing his truth, tried to take some deep breaths and figure out a better plan of attack. After that moment passed, and learning that the 7.8 magnitude quake was Ecuador's biggest in several decades, my next priority was to contact my parents, knowing they would be terrified if they found out about the quake in the news, and couldn't contact me.

We eventually made our way back to our hostel, accompanied by our new friends, because they had been staying in a multistory concrete hotel, now without power, with small pieces of plaster from the roof falling, and decided they now felt less comfortable staying there with the risk of aftershocks. Luckily, our hotel was one of the only two buildings in the town with power via generator, and by some miracle had also maintained internet connection. After making contact with family back home, and some back and forth about whether there officially was or was not a tsunami warning, we decided the risk had largely passed, and retired for the night. All in all, it was not a best day ever for Mike, having lost his glasses, sustained a bad sunburn, and now lived through an earthquake, all in a matter of hours.

Our hotel owners were exceedingly accommodating, even placing a guard on the beach for four hours to monitor the tide, with a car out front in need of evacuation. When we retired to our room that night, I found my water bottles had been shaken off the bedside table, a broken water glass in the bathroom, the toilet had loosened from the wall, and our sliding glass door to enter the cabin, was now very difficult to slide open and closed. All in all, very minor damage, and we felt lucky to be sleeping that night in a one room cabin made of wood, not concrete, and no floors above us. That night I lay awake for a while listening to the rhythm of the waves. I kept the door unlocked, my sandals next to the bed, and wore pajamas that could double as street clothes, in preparation for the need of a quick escape... Which I did use when a 5.6 magnitude aftershock struck at 2:15am. We both awoke immediately and leapt out of bed, but by the time we made it to our hammocked porch, it had stopped.

The next day,  Mike and I stayed on the beach, almost somewhat guiltily, as we read the news reports and the ever climbing death tolls. We stayed mostly in the shade, watched another beautiful sunset, and had a moment of silence that night at 6:58pm. All the while wondering if we should be doing more to help, but not knowing how. The plan had been to take an overnight bus back home that night, and try to get Mike some glasses the next day. However, there were essentially no buses running, because all the main terminals in the cities of Puerto Viejo, or Manta were inaccessible beacuse the roads leading in or out had been destroyed. Finally, the next morning, we decided to take the long way (and only way) home, involving 4 buses and 12 hours of travel. We arrived back to Zumbahua, where they too had felt the earthquake, and had had to evacuate all the patients outside for several hours. Luckily no damage was sustained here either. 

This past week has been a bit surreal, reflecting back on the experience and the choices we made, that could have turned out a bit differently... where to travel too, what type of lodging to stay in, what we were doing at the moment the earthquake struck. For several days after, I continued to have nightmares about earthquakes, and also wake up in the middle of the night, thinking that I'm moving, when I am really not. I continue to feel a bit guilty for these feelings of trauma, while I nor anyone around me was harmed, in comparison the thousands of others closer to the epicenter who were part of and continue to live the destruction. I continue to think about the poor people on the coast, in the devastated towns, without water, without electricity, without working roads, and with the ever growing smell of decaying bodies in the air. I have heard that many hospitals and clinics collapsed, and while some makeshift medical camps have been set up to compensate, many people are too afraid to seek medical care, for fear their homes will be looted. I continue to wonder if I am doing enough here in Zumbahua, or if I could be more useful going to where the devastation is.

Guayaquil

On our first weekend off in April, Mike and I went to stay with one of this friends, and his family who live in Guayaquil, the largest city in Ecuador. It is a port town, toward the southern end of the country, and has a very costal feel. We had a great time exploring the city, parks, and waterways, and it was so nice to have a local "tour guide" showing us around, Mike's friend Lenin. Here are some photos from our weekend:

One of my favorite fruits in Ecuador.

 

Adventures in the Emergency Room

Every other weekend, Mike and I help in the emergency room when there is no clinic. We often encounter many interesting things that we would not see in the US, due to more modern medicine, greater health literacy, and vaccinations. One interesting case we had was a 5 week old baby who had abruptly stopped eating the morning prior, without any other source of illness. Parents delayed seeking care until he hadn't eaten in over 24 hours. When he arrived to our emergency, his fists were clinched, and he was foaming at the mouth. He kept having what looked like either muscle spasms or seizures, where he would get ridged and shake, and draw his legs up. Mike and I both suspected that he had tetanus. At 5 weeks, he would not have been old enough to get a tetanus vaccine yet, but in the US, most women get a booster during their pregnancy to pass temporary immunity on to their babies. No necessarily that case here, where most women never have a single prenatal check-up.

After we had given him a dose of anti-seizure medication, I checked on him and realized that he was no longer breathing and his heart rate was dangerously slow. Mike and I immediately started CPR, with both my hands encircling the little baby's chest, compressing 100 times a minute, while Mike gave breaths through a mask and ambu bag. Once his heart rate returned to an adequate rate, one of our doctors around that weekend is an Anesthesiologist, so she intubated the baby, and Mike and I boarded the ambulance. I gave the ambu bag, attached to the breathing tube, a squeeze every 1-2  seconds to breath for the baby, during the hour long drive to the next level up hospital in Latacunga. I watched the oxygen monitor to make sure the baby was getting enough aeration. Mike had to take over the breathing for the baby, so that I could pause to vomit, as I have had to do now each time, careening down windy mountainous roads in the back of an ambulance that has no windows.

When we arrived at the hospital in Latacunga, we had to keep bagging the baby for 15 minutes more, before they were organized enough to take over with their own staff. Unfortunately, the baby would have to be again transferred to a larger hospital two more hours away in Quito, because this hospital did not have a ventilator machine for a baby so small. By the time we got there, the intubated baby was limp, and no longer having muscle spasms, so our preliminary diagnosis of tetanus was now being questioned. It could also have been seizures secondary to a meningitis, but unfortunately we may never know for sure. In these types of situations, you have to just hope for the best, and turn over the care to the next best thing, even when it is so hard to do because you doubt the quality of care that they will receive when you leave them behind.

That same night, after coming back to Zumbahua from dropping off the baby in Latacunga, we had just drifted off to sleep, when there was a knock on our window, and we were called back up to the hospital. The doctor sleeping in the hospital that night had called us for back up, because simultaneously, there was a mother who had delivered her baby in the street on the way to the hospital, her baby arrived with rocks all over him; a child with a femur fracture who was bleeding into his thigh compartment and needing urgent transfer to Latacunga for emergency surgery before bleeding to death, and then came in another pregnant woman who was fully dialated and ready to deliver. We immediately transferred her to the delivery room, where she pushed twice, and the baby was handed to me. Finally after getting all the charting done, the newborn babies tucked in with their mother's, and the child with the femur fracture transferred, we went back to bed at midnight.

This all occurred the day after Easter. On Easter, we had another exciting day, with a man who presented to the ED, he had been in a glass bottle fight with his own brother, and was bleeding profusely from his hands and head. It took Mike and two other doctors suturing for hours to close up his 10 wounds, he had a bleeding artery ruptured in his head, a ruptured vein in his wrist, and a severed tendon in his other hand. The other 5 of us nurses, were helping facilitate supplies for the suturing and applying pressure to the arteries and veins to stop some of the bleeding. I had never seen so much blood come out of one person before.

Immediately after we got this guy cleaned up, a baby presented with high fevers and seemed to possibly be in shock. We discovered some stiffness in her neck and ended up having to do a lumbar puncture to rule out a meningitis. Luckily everything turned out well with this baby, who did not have meningitis, and was able to go home a few days later. On the weekends here, you never know what will present though the emergency room doors. It has been a crazy adventure and an amazing learning experience all at the same time.

Mike and I on a double date in Quito with some friends from the hospital.

Beautiful rainbow, that I could see end to end from the ambulance, after a rainstorm on the way back from taking a child to the hospital in Quito.

 

 

Cultural Observations

This week I will write about the many cultural differences I've encountered while working here, especially in a medical and nursing capacity. But first, I would like to mention the exciting news the little Marisol is out of the hospital, and recovering with a caregiver at a home in Quito, where the altitude is a bit more manageable. We don't have a date as to when the surgery will be, as she still needs to regain a bit more strength since her recent intubation in the Pediatric ICU, but it is in the works.

One of my favorite parts of working here, is getting to be present for the births. I find it such an amazing experience, every time. I get to be the first one to catch the baby, after the obstetrician pulls him or her out of the mother. I rub the baby down with a sterile towel, to stimulate them to give their first cry, and sometimes use a bulb syringe to suction out their nose and mouth. After the cord is clamped, I carry the baby to the adjoining neonatal room, and put them under a warmer, as I do their first newborn assessment, checking their lungs and heart beat, that they have 10 fingers and 10 toes, height, weight, and head circumference.

Then comes the funniest part to me, is dressing the baby. In the US, to my knowledge, the baby just gets wrapped in a blanket and handed to the mother, but here, oh no, you have to fully dress the baby before handing them off. For me, this is often the most technically difficult, to get undershirt, long sleeve shirt, jumper, booties, mittens, and hat on, a newly born, squirmy, sticky baby. But so it goes. And since no one here ever knows the gender ahead of time, it's anyone's best guess, and I'm usually dressing baby boys in bright pink, and girls in blue. So we start early breaking gender stereotypes.

The mothers and babies usually stay about 48 hours if all goes as planned, before going to their homes. From there, it's customary that the mothers stay in bed, all bundled up, for 40 days. I'm a little foggy on who takes over the housework and childcare during this time, whether it's the father, or the mother's extended female relatives. We have had several newborns who have had to be re-admitted to the hospital for various reasons such a newborn jaundice, fevers, or low oxygen saturations. Often the mothers are very upset that their 40 days in bed have been interrupted, and strongly dislike being here. We try to be culturally accommodating and provide the mom a bed that she can sleep in at night at least, where as all the other mothers of older children are sleeping beside their child's bed in an upright or reclining chair.

Care of the umbilical cord is also an interesting topic. Many parents wrap a long piece of cloth around their babies waist, to "keep their belly button inside." Others might put a silver dollar coin over the umbilicus, intending to prevent an umbilical hernia. None of this is backed by any evidence, but it is a cultural norm here. When the babies come into clinic, they are often so bundled up in multiple layers of blankets, pants, shirts, with a dress on top, that it takes a good several minutes to get down to some skin to do an adequate physical exam.

View of the mountains from sitting at my desk in my makeshift consult room, that I moved to during the surgery brigade that is here for 2 weeks and using the room I am normally in.