Final Thoughts on Ecuador

This picture is just to grab your attention!! But focus over here, not the picture!! Unfortunately the time has come, and I must return to the US. My last week in clinics was interesting. I was really hoping for some good time in the Neuro, but it didn't work out as well as I would have liked. The first day I was supposed to meet with the general surgeon I had worked with before, and he was going to send me to Neurology. It didn't work out that way, I went with him to surgery (a chole-lap) and then he said he would send me there... well somewhere between the OR and his office he disappeared. So no neuro for Monday. Tuesday was about the same, never was sent to neuro. Wednesday I went straight to neuro to find out that I need a certificate to observe in neuro, so that was a no go. I didn't get the certificate until thursday night. But thats the end of probably the most negative paragraph you can find in my blog!!

Friday was my first day in neuro, and last day of clinics. Neurology is on the tenth floor of the hospital, and is made up of about 20 rooms with up to three beds in each room. I don't know if it is mandatory, but all the residents in neuro were women and very beautiful. No surgeries on Friday, just rounds, but thats not to say it wasn't interesting. The first patient I saw was a women in her thirties who had tumor removed from her front left lobe of her cerebrum. The surgery was 30 days prior, but she was admitted because the suture became infected and was beginning to reopen. The next patient was a man in his twenties that was in a "transit accident" (that's all I got out of it) and was quadriplegic. They were monitoring his organ functions, which were normal. I tried to not let it get to me, but it was very sad to see someone not much older than me that will never walk again. But then what is "right" from a physician's point of view?? Is it "professional" to allow yourself to feel for a patient or should you be numb? Or is a definite point along a continuum between the two??

That about sums up the interesting cases. After that I felt like one of the interns that I so comically observe being grilled by a doctor. One of the residents who was very eager to teach had me read several pages (in spanish) about anti epileptic medication. After the reading she quizzed me (in spanish), which was very difficult to remember everything that I had read. She was really grilling me at some points and I felt like I knew nothing, but in the end was fun and now I'm a semi-expert on such medications. It was great to see someone in their residency who was still so passionate about what she was doing. She went off on several tangents about how great Neurology is and how I MUST specialize in it. 

Now that I think about, this wont be my last blog, I'll really wrap things up when I get back to the states, and I'll review everything I have learned about Ecuador as a country!

A half-week in Cardiology

I'm fresh out of the jungle and glad to have spent a weekend out of the city so i'm refreshed and ready to lay down some info. I went to Mindo, which is a small mountainous town outside of Quito to the northwest. Mindo is lower than Quito, but still about 1300 meters above sea level so it isn't exactly low either. This a great view of the city on the road that takes you up to the zip lines, the waterfalls, and much more. Mindo is very small and a very tranquil town. Its very relaxing at night if you get away from the one main street and one can fall asleep to music of the jungle: birds, water, and whatever else. The girls went ahead of me because I had clinic in the morning, but they picked a great hostal (thats how its spelled in spanish). When you start up the hill to the hostal you can smell the cocao from the chocolate factory that is across the street. On the other side is a small river and when combined with the birds singing, it creates a very relaxing ambience.

Somehow I got stuck up in the loft room. It was funny because I had a hard time getting in and out of the room and the door didn't even come up to my waist when I stood up, but the only part of the room I could stand was the middle. The stairs are very steep and very small. Somewhere between to combination of too many tequila shots, wet shoes, and no room for my feet I fell down the stairs which was comical relief for about everyone but me.... but now its funny. For such a small town Mindo has a lot to do. Butterfly farms, a chocolate factory, zip lining, tubing in the river, waterfall tours, nature hikes, and much more but that's all that comes to mind. Its quite the contrast to Quito. There is only two bars in the town, and really only one paved street. One can easily see the city in less than half a day, but its what's around the city that's important. To get to the main attractions like zip lining, you have to catch a pick-up taxi that takes you up an old logging road. Before 1990 Mindo was a very big exporter of logs to Quito. People were ignorant to the harmful effects of limitless deforestation. In 1990 (this is according to a cab driver who has lived there his whole life) the started passing laws to protect this area, and now any form of deforestation is some serious jail time. Mindo is a cool town because everyone is very friendly, and everyone's primary goal is to preserve Ecuador's forests. The city runs on tourism with a very high amount of Ecuadorian tourists, and of course people form all over the world.

We spent most of Saturday zip lining and after a chocolate factory tour. There are 13 lines of zipping around the cloud forest. It was cloudy the entire time I was there, but I honestly feel that I prefer it that way because it really adds to the jungle feel of the town. It was fun because a lot of times I couldn't see where the zip line ended so you just disappear into the clouds. After the zip line was the Tarzan Swing (to the left). This was quite the rush. You stand on this platform while they hook you to a rope that is about 70ft long (my length judgment has never been good). Then the open the gate of the rail and you fall!! The first part of the fall isn't like a swing at all. It feels more like a free fall which really caught me off guard. The swing then catches you and you swing back and forth through the jungle. Quite the rush!! Afterwards was chocolate factory tour. It was very interesting to learn the history and the process of making chocolate. It started with the Mayans, and quickly spread throughout the world. Its a pretty simple process too. Basically you just extract the cocao seeds from the plant, ferment them for six days, and dry them. Once you have the dry product they run it through a machine that shreds the seeds to make "nibs". Then they press the nibs and grind them and they liquify. The coco butter is extracted, and then the brown "chocolate" is ready to go. In this form it is extremely bitter and I tried way too big of a spoon full. Then the addition of sugar completely changes the flavor to the well known chocolaty flavor. We sampled some of the other products that are made in Mindo including some BBQ sauce that is to die for and some incredibly brownies. I got a copy of the recipe and the VERY important Quetzal chocolate for making them so you loyal readers better start sucking up if you want to try them... and if you want a Mellor steak with Quetzal chocolate BBQ sauce!!

Sunday was waterfall chasing time. We hopped another 4X4 taxi to the top of one of the mountains where we hiked down into a valley where the river (I forget the name) snakes through. Its a really mellow hike, but I could still feel the altitude a little. We only went to one waterfall (Nambillo) because we were limited on time. Apparently one can jump from the waterfall and there is a guide to show you how to do it but I saw no guide, and I couldn't tell how deep the water was so I wasn't jumping in. There was another platform about thirty feet above the river in another area, but after assessing the depth it was barely over my head so there was nowhere I felt comfortable jumping from. The water reminds me of the North Umpqua in about March. The water looks the same, with that light green color, and is VERY VERY cold!! We caught a ride back to Quito with the lady who owns the Hostal we stayed in. It was nice to avoid the bus ride, and we chatted in Spanish most of the way back. A lot of times my bus partner doesn't want to talk to me... She is actually German and her Son married an Ecuadorian women and have two kids. She drives them to Quito every Sunday for school and back to Mindo every friday. Seems like quite the pain but apparently the school in Mindo is a bit below par. Aside from having to commute so much, the kids are very lucky that they're learning German, Spanish, and English.

Since this post is titled "A half-week in Cardiology" I better get on with last week in the Hospital. From wednesday on I was in Hospital Militar with Dr. Aucancela, a cardiologist. If you have been paying attention to past blogs you should be familiar with this hospital (yes there will be a test at the end). This hospital is private for Military personnel and their families, and almost all services are free. For active or formerly active personnel everything is free from their medication to any type of surgery (save for esthetic plastic surgery I would imagine. As a side note, it is very popular here, but not in the hospitals... private clinics). For family everything is free except very spendy surgeries, but are still very affordable. The first day was consults with the Doc (office above). He is very animated, and a great doctor. He has a way of making each patient laugh and smile, and has a very personal feel to his demeanor if that makes any sense. Its no wonder why half his patients bring him a gift, anything from wine, to liquor, to christmas ornaments. He was very great to me and I feel very fortunate to have spent part of a week with him. He would stop in his tracks and sit down and explain everything that I didn't understand. His consults felt like going out for a cup of coffee with friends minus the coffee. I can't even begin to write everything I learned from him because I feel I would bore you with details, and I'm too lazy. I have to write weekly reviews of what I did in the hospital for the credit portion of this program, and i'm not writing everything twice. I know it would seem logical that I could just copy and paste what I wrote, but its very dry and I couldn't do that to my loyal followers.

This is Dr. Aucancela and me on my last day. He usually always smiling and cracking jokes but I think he got a little camera shy.

Diabetes and hypertension are prominent problems here. It is mostly due to sedentary lifestyles, poor alimentation, and diets very high in salt. Every traditional meal here starts with soup, and whats is soup?? Lots of salt!! Plus every other type of food tastes very salty. In short I learned a lot about how hypertension has no cure and how it negatively effects the retina, the cerebrum, the kidneys, and obviously the heart. One fun fact I learned is how pure oxygen is a vasodilator, so a hypertension patient who is taking some form of vasodilator in Quito must lower their dose if they are to vacation to the coast or some other low altitude area. I found this very interesting that the same exact patient with the same medication would be prescribed a different dose by a doctor on the coast and a doctor in Quito.... something I never would have thought of. Almost every patient we saw in consult had hypertension, and the ones that didn't had another heart condition like an 8 month old boy who needed heart surgery.

Thursday was full of Echo Stress tests. The type I saw was Chemical Echo Stress tests. Basically this is used when some type of cardiac irregularity is suspected, whether its an irregular EKG, chest pain, arrhythmia, or most commonly used with suspected Coronary artery irregularities. A patient is a candidate for this test if they fit the "suspicion" criteria, and are unable to exercise. The chemical they use here is Dobutamine, which is a direct-acting inotropic agent that stimulates beta-receptors. So basically it increases cardiac output and induces vasodilation. With the heart under stress, problems are much easier to see with an echocardiogram. The target Dr. Aucancela shot for was 140 BPM. They would observe the heart with four different concentrations of Dobutamine and watch to see how the heart recovers. Of the five Echo Stress tests, only one resulted in a find. A 50 year old woman had a Mitral valve adenoid which was obstructing it. She had the valve replaced 30 years prior, but unfortunately she needs surgery again. It was really interesting to see how the blood would swirl around in her left atrium (I think thats right, forgive my heart anatomy) instead of passing freely through to the left ventricle. The rest of the tests were negative, mainly just old ladies concerned about chest pain. Another note was how all the patients were women. I asked the Doc why that was, and says its due to why a patient needs a Chemo stress test: some type of disability so that they cannot exercise. He says the main examples are old age, arthritis, and knees problems. Apparently that is more common here among women, i'm not educated on the subject because my only Orthopedic background is surgery in Chone.

Now this week I am back a the military hospital in neurology, so hopefully everything follows through, and if i'm fortunate i'll get to see some neurosurgery. This is my last week here, and its going to be a bittersweet departure. I love it here, but I feel its time to get on with my life!!!

Recap on This Week

Friday was one of the most exciting days I have had here. Fridays procedure was repairing a Bilateral Inguinal Hernia on a 50 year old patient. I'm not sure if these are usually repaired laparoscopically, but this was an open surgery.

Not to far into the surgery, one of the interns who was assisting fainted, and apparently it wasn't her first time. It caught me by surprise because I wasn't paying attention to her, I was watching the surgeon. I saw here out of the corner out of my starting to walk away from the surgery and then she said she didn't feel well and the surgeon started yelling "Cógale, Cógale" (which means "grab her"). I was on the other side of the cables that were feeding the cautery so I couldn't catch her, but she was so small I was able to reach over and hold her up by her arms until the anesthesiologist ran around and grabbed her. She was definitely out cold, I remember seeing her eyes roll up as I let her go and the anesthesiologist was laying her on the floor. 

To my good fortune, the Surgeon asked me if I knew how to scrub in. I was very glad I had plenty of practice in Chone and I had been watching them scrub in for the last week. Needless to say I scrubbed in and helped finish the surgery. I held the skin separators and held two strings that were holding the Vas Deferens and the Testicular Artery out of the way. Obviously the view from the patients side is much better than peering over the Surgeons shoulder the whole time.

This picture was taken a about a minute before the intern fainted. They repaired the hernia by using a synthetic mesh called "malla". According the surgeon, this procedure is not used that often in the states because it is very difficult, I can't confirm or contradict because I don't know what is common. The mesh approach cuts down on having the suture the muscle back together in a high tension, "unnatural" way. The mesh is sutured to cover the hernia, and acts as a lattice for new tissue to grow. Therefore the mesh stays in for the rest of the patient's life. One cool things about this picture is how you can't tell due to its a picture, but every time the cautery would touch the muscles, the abdominal muscles would contract due to the electrical impulse. 

At the end of the surgery the surgeon thanked me for helping. Even though I feel I should have been thanking him, I felt very honored that I was actually needed because there was no one else who could scrub in. It was a great feeling because I wasn't a burdensome student who wanted to get their hands dirty. After the surgery he explained everything I saw and how the synthetic mesh worked. I found it interesting to learn how during a surgery like this, the most common problem (and therefore cause of malpractice suits) is damage to the testicular artery and Vas Deferens. According to him, he has only seen two post surgery complications like that in his career at the military hospital (I don't know how long his career is). As a final not on the surgery, I was surprised that they only did a local on the patient's spine, they didn't put him under. 

I talked to the intern who fainted after the surgery and she was telling me how much she hates surgery, but she has to do it was apart of her school. She wants to get into family practice and has no interest in surgery. After that I had a short chat with the chief of surgery about why Gall Stones are so common here. According to him, he feels the bad diet here is to blame, much like the doctor at the Maternity hospital feels the bad diet largely contributes to a high incidence of Preeclampsia (although there is still no known cause for preeclampsia). The day ended on an interesting note. My host mom's oldest daughter bought a new Suzuki SUV but is out of town. She needed to have it picked up, but my host mom was scared of how big it is, so I ended up driving it home from dealership. I know it doesn't sound like that big of deal, but one must see how people drive here before realizing how nerve racking it is to drive a brand new SUV that isn't yours in a foreign country. To add to that, i'm not sure that its even legal for me to drive here... but nothing bad happened so its just a good story!!

Now back to Tuesday, Its my blog and I'll write backwards if I want to!! Since I was fortunate enough to  meet the Chief of the ICU at the military hospital on monday, I spent Tuesday morning in the ICU. Its a fairly strict area. The door to enter is locked and you have to buzz in and explain who you are before they will let you in. I met with the Chief in his office, and then we walked down to the ICU. You have to wash your hands before you walk in, and you have to sanitize your hands before every new patient even if you don't touch them. I apologize for the lack of photos for this section but it seemed inappropriate to take pictures. 

The ICU is a 13 bed unit with a mix of pediatrics. While I was there the Pediatric Doc was gone so they just refer every case to another private military hospital. The first patient was a 53 year old man who had prostate cancer (along with a long list of other illnesses). He was going through chemotherapy and was having heart complications which was related to his cardiac bypass three years prior. He was suffering from supra ventricular tachycardia when he was brought in, but was stable when I saw him and they were planning on continuing the chemotherapy. The next patient was a man in his sixties who suffered an Ischemic Stroke. He lost all movement on his left side so guess what side the stroke was on. He was in the ICU when he had the stroke, he was recovering from surgery on a left side aneurism. According to the doctors he had aneurisms on both sides but they only operated on the left side. During the surgery he began hemorrhaging, and suffered from cerebral edema. When I saw him he was intubated with a feeding tube and the Doctors felt he didn't have a very good prognosis, but they were waiting for the next day to take more CTs. I'm not sure if they have DNR's here, but they told me it will be the decision of the family to keep him alive if he is in a vegetative state. 

Other patients included an older woman who was in a car wreck who suffered from cerebral trauma and trauma to her hip and chest. Another patient was an alcoholic with a whole list of problems. He was in for kidney failure. He had a transplant 10 years prior and his "original' kidney was failing. Another interesting case was a man in his 60s who suffered a bilateral stroke. He was intubated and I found it interesting how they used a sternal rub test on him, and also nipple twist (Not sure if there is a medical term for that). 

Wednesday wasn't very eventful. The doctor I work with had consults, so I went down to the OR. It was fun because I just floated from surgery to surgery and watched. Some of the ORs have windows so you can watch from outside. There was one plastic surgery (not esthetic) and they were working in a man's right nostril but I was only watching from the window so I don't know what they were doing. I watched some of another Cholelap, what looked like some type of angiogram, and surgery of a the ductus arteriosus of an 8 month old boy. By concept it was interesting, but I couldn't see anything so it wasn't too interesting. It was interesting how the Surgeon worked from the child's left side. 

Thursday I didn't go to clinic because we went to the Toros. So now i'm going to talk about the Toro so if you're strongly opposed to animal abuse or anything along those lines I suggest you skip the section (that means you mom!!)

Now I will not deny that yes the Toro is celebrated animal abuse, but it is much more. Above is the Plaza de Toros. Its a fairly large stadium, I couldn't begin to guess how many people it holds but there wasn't a single empty seat in the entire stadium. Its a fun stadium because its next to the airport so you get 747 flyby's every ten minutes. As abusive as the Toro seems, it is a very artistic display. 

Now on to how these particular Toros work, because there are different types. It starts out with releasing the bull into the stadium. Several men are in the ring with yellow and pink sheets (capós). I think its a process of fatiguing the bull but don't quote me on that. The first bull that came actually got loose for a short period. The gates that open to the stadium for the horses to come and go wasn't completely closed, and the bull rammed the doors open. There were several people behind the door along with a couple horses. The crowd started screaming (in horror) but no one was hurt too bad. After a while two men on horses come out carrying large lances. 

The horses are dressed with large blankets that extend down to their hoofs for protection. I think it has some form metal also to protect the bull. At this point they basically purposely let the bull ram the horse (stop reading mom) but the horses aren't harmed. While the bull rams the horse the guy on the horse lances the bull. Then the men on horses leave while several men distract the bull.

Here you can see the men with the pink and yellow sheets. Next the men come out with short spears that are dressed with assorted colors of fabrics (banderillas). They definitely have a very dangerous job where they run straight at the bull and lance it. Two men do this with two banderillas each. After this the main Torero comes out. He has a red capó and a sword. This part is seemingly artistic because they appear to be dancing with the bull. 

Here is one of the main Toreros. I believe this one is El Fandi, who is a favorite with the women. Each Torero has their own style and routine. One got on his knees while the bull was running at him and others would do things like make the bull do circles and put their hand on it (which was another favorite with the crowd). The bulls did get some revenge. One Torero got a horn right to the shoulder. He was pretty hurt and very fortunate he wasn't stabbed, or maybe I would have been seeing him in the hospital haha. Another guy was hit and tossed over the top of the bull but he was fine, just a little shaken up. Then it would get a little more graphic. The object is to get the bull to charge and then stab its heart from above (ie through its shoulder). Only one Torero successfully killed the bull the first time with this technique. In the case that they don't, they use another sword to stab the bulls spinal column. Then horses come out and drag the bull away. Sorry if this section was a little unpleasant to read, but I felt the need to tell it how it is.