Newest of the New

No beating around the bush i'm just going to jump right into this one. Lets start with whats fresh in my head. This week I'm back at the military hospital (Hospital Militar). This is a private hospital for military personnel and their immediate family. I would say that its one of the better-supplied hospitals in Quito.

The last thing I want is for my blog is it to be a source that is fueling some kind of bad reputation for Ecuadorian surgeons, but I must be bad luck for Cholecystectomies even though I don't believe in luck. The reason I say this my first day back at Militar there were once again complications in an usually short laparoscopic procedure. I hate to beat this into the ground but I want to make it perfectly clear that these stories are written with no intent to disrespect any of the health professionals at Hospital Militar.

Above is the OR where most Cholelaps go down. This is while the surgeon is putting the four ports. This is the third different surgeon I have seen perform a Chole and its very intriguing to me how each surgeon has their own respective style. Like I commented before, one surgeon works between the patients legs, and the others to the patient's left. Every surgeon puts the camera port through the navel, but all other ports are respective to the surgeon. 

From the beginning the surgeon continually made comments about what a pain this specific gall bladder was and how he had never seen one like it. He commented several times on how the excess fat surrounding the gall bladder made the surgery very difficult "Una vesícula grasosa". 

While cutting the fat away from the Gall Bladder the surgeon accidentally made a small cut in the wall of the Gall Bladder. Right away bile started pouring out followed by many small gall stones. At this point the relaxed mood of the OR turned into a mix of frustration and hurry. Due to the location of the cut, the gall bladder essentially evacuated into the patient's abdominen. The surgeon wasted no time: he removed all the laparoscopic equipment and began making a large incision in the patients right upper quadrant, as shown above. One thing I found very surprising was how the surgeon called in another surgeon to help. From this  point it was pretty routine. 

Above is just before they stapled the gall bladder and cut it out. At this point the mood of the OR changed again back to the more relaxed, usual atmosphere. 

Here the surgeon is inspecting the gall bladder. Where his left thumb is marks where he accidentally cut.

I never took the time to count, but these are all the stones that leaked out. This doesn't include all the stones that were still in the gall bladder. In my amateur opinion, this seems like quite a bit of stones!!

While having the patient open, the doctors also discovered this. New to me, it is a case of Meckel's Diverticulum which is an usually asymptomatic deformation in the small intestine. 

Now i'm going to jump back to last week. Due to my unfortunate sickness the week before, I returned to Tierra Nueva in the Emergency room. This hospital is also called Padre Carolla, who was a priest in Quito. He started a foundation with the view of providing good, affordable healthcare apart from the public system. It is interesting that this particular has a lot of financial support from many international sources. According the doctors at Padre Carolla, this hospital falls somewhere in between public and private. It is open to the public but not free like public hospitals. Not to say that is not very affordable. A routine consult only costs a patient $4 and a normal birth costs $100. Unfortunately I don't have any pictures from Tierra Nueva so this section will be all words!!

The hospital is the second nicest and advanced one I have seen in Ecuador (please excuse my repetition if I have already talked about this). I only saw a few interesting cases while I was there, but I had the opportunity to spend a lot of time with several residents and interns and I learned a lot about some of the problems with the medicine in Ecuador. The first notable case I saw was a young girl who was having a heart attack. She suffered from antiphospholipid syndrome which from what I have found manifests as a very complicated syndrome so I not begin to try to explain for fear of giving false information!!

Another interesting case I saw was a 4-year-old boy who fell playing in the park. He hit his head on some metal part of the park structure and had quite a large laceration on his forehead. It stretched from below his left eyebrow across his forehead to his upper hairline. The cut was deep enough that you could see his skull. The kid was surprisingly calm, and I feel bad for him because he will always have quite the scar on his forehead. I asked the doctor about taking a CT and he said it wasn't necessary. Even though the kid displayed no signs cerebral damage it just seemed necessary to me, but thats simply my amateur opinion!

The one night shift I worked at Tierra Nueva was fairly slow. I worked from 8pm to 3am and the only case I saw apart from people with the flu was a highly intoxicated male who had fallen and cut his head. What was surprising to me was how this fairly small laceration was bleeding profusely. Blood was basically pouring out of his scalp, much more than the young boy with a cut four times the size. Maybe as punishment for being stupid and drunk but the doctor didn't bother with a lidocaine block, he just cleaned it up and sutured him up. This goes without saying but the man had a tough time dealing with the pain of getting his head stitched with no local anesthesia. He was heavily intoxicated however, so maybe he wont remember anything. After about 1am the ER really slowed down. I spent a lot of time talking to an intern about the problems Ecuador has in Medicine.

One major difference from the states is there are no "drug seekers" that come into the ER looking for drugs. Every patient that comes in is genuinely in need of help. According to the intern there is no problems with patients seeking narcotics due to a newly implemented system that makes it fairly difficult to get narcotics. I'm not entirely sure how this system works so I will have to get back to that. One problem she emphasized was antibiotic resistance. Due to careless administration of antibiotics there is a high prevalence of antibiotic resistance. According to her, doctors here have a tendency to give antibiotics that are much stronger than necessary, which has been leading to this problem. 

Another problem she touched on was inadequate ambulances. Apparently it is rare for medical professionals to be present in the ambulances. This also depends on the hospital, because each hospital also has their own ambulances (public vs. private). A lot of lives could be saved if this system were to change, but right now there is only one school in the entire country that teaches EMT-like courses. A sad example is how she lost her brother a few years back because he was having heart complications but the ambulance had no one with adequate knowledge to help him and by the time he arrived at the hospital he was in a vegetative state. 

I hate to end on a sad note but thats all I have for now. I'm back at Militar and i'm hoping to see some great surgeries this week because my time here is slowly slipping away!!

Back in Quito

Forgive me for my tardiness with updating my blog but I feel I have a valid excuse. I've been bed-ridden for the last three days and i'm finally starting to get better. I was down with a really bad fever with lots of joint pain, dizziness, headaches, and nights sweats. A bad cough and a sore throat put the icing on the cake. After a visit to the hospital yesterday and some magic shots (antibiotics) things are starting to look up. This seems like the worst place to get sick because right now its cold and raining (much like Oregon) but one can definitely feel the altitude on top of it all.

It was ironic being in the ER here, it was like a "student becomes the patient" experience.... I look at it all as part of the cultural experience. But enough about poor, poor, pitiful me, lets get to the good stuff.

After an initial two days of full-day classes I started back up rotations at Hospital Militar (try to say it with an ecuatorian accent). Above is the view from the eight floor looking north. Here I work with Dr. Vargas who is a GI surgeon. My first day here was a very eventful day. Within twenty minutes of being there we headed down to the OR. This hospital is much bigger than in Chone. I never got an accurate count but I saw around 10 ORs. I actually didn't get to see a surgery with Dr. Vargas this day (or any day for that matter) because he sent me to watch an aortic valve replacement. 

Getting to see this was a very rewarding experience. The surgeons were obviously very busy and not able to explain much but I was fortunate that there was an anesthesiologist who was very helpful. Initially I was every surprised how much human ribs can stretch apart with minimal damage. I was honestly almost more fascinated by the cardiopulmonary bypass pump than I was the actual surgery. It was very interesting to see the process of when they had the patient intubated and then switched to the 

CPB pump by using propofol to induce sleep. Then they packed around the heart with frozen saline solution to lower the heart's metabolic activity. It was surprising how at that point the heart could go over 3 minutes without any tissue damage. If I remember correctly they ran a line directly into the aorta, and one coming out of the Superior Vena Cava but don't quote me on that. They also ran a line to each coronary artery and would feed it every three minutes. 

No real justification for posting this picture other than I think its was a good picture. To the right closest to the patient is the chief cardiologist at Hospital Militar. Unfortunately I couldn't stay for the entire procedure. I left when they were suturing in the valve into the aorta. I would have liked to see how they brought him back and closed him up, but not this time!!

The next day at Militar was not quite as eventful as the first day's surgery but I learned a lot. The day started with rounds with Dr. Vargas. Almost every patient we saw were post-op cholecystectomies. I never got a chance to ask why gall stones have such a high prevalence here. It was fun to watch the Doc quiz all the interns and try to answer the questions myself (in my head). Dr. Vargas grilled one of the interns pretty hard about he thinks of medications first for a post-op patient, not wound care, vitals signs, physical exams... etc.  The day ended with a presentation the human bodies response to surgery. The doc had some great points that really hit home: Most people think of surgery as a benign process, but it is indeed a trauma. Its comparable to a car wreck or some other major wound, the only difference is with surgery you're asleep. Although you're asleep, the body still has a stressful response to a major trauma. For this reason they're pushing more and more towards less and less invasive procedures. The presentation went over all the different responses the body can have to the trauma of surgery like anxiety, pain (obviously), hemorrhaging, increased vasopressin levels, increased cortisol levels... etc. 

The third day at Militar started out routine but turned around quite quickly. I went straight to the OR (they call it Quirófono in Spanish) to see two cholys. I'm not sure if thats how you spell the abbreviated  cholecystectomy so forgive me!! The first surgery was a laparoscopic choly, as I believe all are at Militar. Everything was going to plan until the surgeon hit an artery. He was unable to stop the bleeding so they had to pull all the laparoscopic tools and switch to a full-open surgery. It was amazing to see how fast a surgeon can open someone up when the time calls for it. I want to make it clear that by writing this I mean no disrespect to this surgeon, the hospital, or any surgeon in Ecuador for that matter. Even surgeons are human and make mistakes and this was not due to carelessness but simply a mistake. From there the surgery went very smooth and the patient was fine. 

I watched a second laparoscopic choly. Basically identical minus the mishap, but it was interesting to watch how two different surgeons have their own styles. For example one surgeon worked from the patient's left side while the other worked by standing between the patient's legs. Due to their different positions they also made incisions in different places, and how they went about cutting and cauterizing the arteries feeding the gallbladder. 

This week I started in the ER with a resident at Tierra Nueva. By far the most advanced hospital I have seen here. Its brand new and is a very classy hospital. I was pushing it going to clinic that day and paid the price. I was pretty sick for all of the day and was unable to make it to class. I haven't been back since, but hopefully i'll be 100% ready to go back next week. 

Final Thoughts on Chone

Well i'm back in Quito now and I want to wrap things up with respect to Chone. I've adapted to the costal weather and i'm in the process of getting used to Quito again. In other words, I get winded walking up stairs and I'm not sweating all day like I was used to in Chone. A thought thats been marinating in my brain for the last few weeks that i've been dying to get out is what it means to be "Chonero".

First off, what is a Chonero?? If its not too obvious, a Chonero (or Chonera) is anyone from Chone. What is Chone?? Chone is a small town in the coastal region of Ecuador on the Chone river. As said by the doctor I worked with the last three weeks: "Chone es al cuidad de las naranjas, las mujeres hermosas, y los hombres celosos" (Chone is the city of Oranges, beautiful women, and jealous men). I couldn't agree more. Oranges are definitely a big deal in Chone (along with bananas) and the women in Chone are very beautiful.

Perfect example above of the beautiful women in Chone (Nurse Roxana and Secretary  Yajaira). But back to what it means to be Chonero. I can't help but draw a parallel between Choneros and the stereotypical American Redneck (no disrespect to the Chonero). What I mean by this is that Choneros are a very hard working group and they're very proud of how hard they work and they're very proud to be from Chone. When you ask them where they're from they always answer "cien porcento chonero". Thats about where the parallel ends. Choneros are some of the nicest, outgoing people I have met in Ecuador. Everyone knows everyone, and they love to stop me on the street just to ask how my day is going, where i'm from, and what i'm doing in Chone. My last week in Chone i'm pretty sure I was the only white person within a ten mile radius, so I got stared at on a constant basis, but after a while I became immune to it. 

In comparison to other regions of Ecuador, Choneros have a very relaxed lifestyle and consider themselves much different than other Ecuadorians. Those who live in Chone work hard and live life to its fullest (sounds so cliché, but these are direct Chonero words). When they get up, they get up, "cuando se levanta, se levanta". They believe this lifestyle is better for the health and in no way do I disagree. They work hard all day, and then relax in the afternoon and night. Most of this is coming from a lengthy conversation I had with a man in the hospital in Chone whose daughter was recovering from surgery. He talked about the country and everything out there was better than the city. The chickens range free of fences and chemicals. He went on about how the fruit grows bigger and tastes better. It was a great experience to see someone so passionate and proud of something so simple. By "United States Standards" Choneros have next to nothing but they are some of the happiest, most content people I have had the pleasure to meet. Its nice to see how happy someone can be without the nicest car, the biggest house, and the fanciest toys. 

Above is my Chone family. Pepe is a perfect example of 100% Chonero. He was a taxi driver in Chone for 30 years and makes for some great conversations during dinner. I'm not sure if he meant to but he never failed to make me laugh everyday. Mariana is a great cook and taught me some great ways to cook up bananas. I have to give her a shout out now for the great food, hospitality, and hand-washed/hang-dryed clothes. Theres only one thing I wont miss about Chone, which is the damn bug bites. I don't know how, but they always seemed to find me and eat up legs and feet!!

Cristina is another member of the family. Quite possibly the cutest 5 year old girl on this planet. She speaks better spanish than I do, and loved to make faces at me while I was eating dinner. I wish I could adopt her but I doubt her dad would go for that. 

This was part of the Pediatric crew I worked with every morning. Everyone was great in Pediatrics. They were always willing to teach and very easy to get along with. Right behind me is Dra. Díaz who makes the whole program in Chone possible. She is a great doctor and a great teacher. She, along with Dra. Tejado to her left, are great people and respected members of Chone. I spent a lot of time with Dra. Díaz at the hospital, in consults, and we spent some good time translating WHO guidelines for Dengue Fever that were in english. Now I consider myself a Dengue Fever expert. 

This is Dr. Vera and Dr. Robosky (left to right) orthopedic/trauma surgeons. I spent a lot of time with these guys. I got to see everything from amputations, to compound fractures, to repairing tendons. Not only are they great Docs, but quite the characters too. They're pretty funny guys. They were really great about teaching and keeping me involved during the surgeries. I won't lie, they were difficult to understand and at first very intimidating (not on purpose). 

This is an example of one of the many surgeries I got to see with Dr. Vera and Robosky. Coming from a construction background its funny how much Orthopedic surgery is just like construction, just much more meticulous.