On a relaxing weekend day...

Today has been a lovely day in Zumbahua. On Sundays like today, we don't have hospital rounds until 9am, therefore I got to sleep in, drink my coffee in bed, and made pancakes for our breakfast (Mike, myself, and Justin our visiting medical student). On morning rounds we got to discharge 4 out of our 5 pediatric patients to their home, always an exciting thing when you get to see the kids make a full recovery.

After rounds, I proceeded to go wash all my clothes by hand. Normally I am a laundry procrastinator, but when you are doing it by hand, you really don't want to let it build up, because even a small amount of washing is quite an upper-body workout. Workout for today... check. Then, since there still wasn't much in the way of pediatric emergencies, I came down to the house to make lunch for everyone. After lunch, a short walk with Mike down to the nearby river. Since we work 10 days straight, it is nice to get outside the hospital compound once in a while, even if it is just nearby for a few minutes. Outside it is a beautiful blue sky day with a light breeze, rare in Zumbahua,  and the mountains surrounding the town are clear and vibrant green. We commented on how much we will miss this beautiful scenery.

Now, as I write this I am sitting in the kitchen, waiting for my big pot of water to boil for 5 minutes, so we have drinking water this evening. I am trying my hand at making boxed brownies (thank you mom!) in our primitive oven, but they are coming out disappointingly flat, probably because of the altitude.  

I enjoy these days when I get to do some of the things that remind me of the comforts of home... leisurely drinking coffee in the morning, backing or cooking in a kitchen all to myself, walks on sunny days. I think it helps prevent burn-out in a place that is wonderful, but can also be very challenging and frustrating at times. It is amazing how fast these last 5 months have flown by. I only have about 2 1/2 weeks left here in Ecuador, and I am trying to enjoy every moment.

 It is neat to reflect back on how much I have learned, how much more confident I have become in a clinical capacity, and how many interesting things I have gotten to experience. I sometimes wonder if in future practice settings I may be bored or Jaded with the run-of-the-mill colds and tummy aches, after being exposed to so many children here who have such complex health needs or "really" illnesses. Or perhaps it will be a nice relief. Either way, I am certain that I will never again have an experience such as this, and I am so grateful for every colleague, patient, family, and especially Mike, who have taught me so much along the way.



Enjoying the view from outside Ibarra, Ecuador

Adventures in Ibarra

On our last weekend off, we took a trip with my friend Sophie, and her husband, to her husband's home-town of Ibarra, in the northern highlands of Ecuador. It was very fun traveling with them as we got to see and do many activities that we would not have known about, or would not have been able to access without a vehicle.

My favorite event of the weekend was when Pablo, Sophie's husband, decided to cook us a crab feast for one of our lunches. We picked up the crabs early in the morning from the market, where they were still live, and tied together in a bundle of 13 or so. Total, was had about 26 crabs, probably brought in fresh from the coast in the early mornign. Pablo preferred to keep them alive until they went into the boiling water, so the real adventure was cleaning the crabs with a scrub brush to get them clean, without getting pinched by the crab. I was a bit tentative at first, letting out a few squeeks and "ahhs" now and then, but eventually I got the hang of it. Occasionally one would get away in the big wash basin, and scurry to the drain, where it would clamp onto the drain grate so tightly that you could not pry it away. The crabs, once scrubbed clean, were a beautiful array of purple, red, and orange.



Our live crabs from the northern coast of Ecuador.

Carefully cleaning each one with Pablo.

 

All finished, ready for cooking.

Eating them was another story. As Mike and I are used to larger bodied crabs, with accompanying shell cracker tools to access the meat, we had small bodied crabs, with only one shell-cracker for the table to share. It is obviously an acquired skill, because Pablo and Sofia skillfully used their teeth the crack the shell, and mouths to suck out the meat. They had devoured a handful of crabs before I had gotten through one and a half, with sore fingers, and crab meat flung all around my plate. They were delicious though.

A few hours later, Pablo's mother heard some clicking in the family dining room, down the hall from the kitchen. She went to investigate and found that one of the crabs had leapt out of the bucket on the floor by the boiling water, while awaiting his turn to be cooked, and had run away, trying to escape his fate. Which he did for about 4 hours, but to no avail, he got eaten later for dinner.

View on our drive up to Ibarra.

Getting to know Lago San Pablo.

Mike holding a falcon at an bird rescue park.

Trying Cuy (Guinea Pig) for the first time.

Volcanic crater lake.

Trying to get an Avocado down from his parent's tree in their back yard.

Re-enacting an Incan sacrifice on a ceremonial sacrifice stone.

Just kidding.

Ibarra by night.

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.