Ida in Otavalo

Week 6: A(H1N1)... the Swine Flu in Ecuador

2009-08-06T09:56:00.000-07:00

A final hello,

For my final blog, I want to draw attention to a global concern that became quite local for me in Otavalo. A(H1N1), the "Swine Flu", has hit Ecuador, and even Ibarra, the city right next to Otavalo. Here, it is called A(H1N1) and it is very scary. A few people in Ecuador have already died.

Although it hasn't hit Otavalo and hopefully won't, the hospital is taking the outbreak very seriously. The director of the hospital called a meeting on the 24th of July for all the rural clinic workers, which included everyone working at Gualsaqui. Maria Esther, Erica, Legia and I went to the meeting where they discussed the dangers of the sickness, and what symptoms to be wary of--sore throat, cough and/or fever. But the main concern at the meeting was a sign-up sheet to work in the triage tent, set up outside the hospital on the weekends. This tent accepts all patients with the symptoms. The tent is to keep epidemic carriers from entering the hospital and allowing the sickness to spread.

Maria Esther happened to sign up for the Sunday just before I left. I was excited for one last experience, and so on Sunday morning we walked to the hospital, meeting the doctor we would be working with there, and opened up the tent. After donning our masks and snapping on latex gloves, we were ready to receive patients.

There were many people who came in that day. There were a lot of babies and toddlers with coughs and runny noses. The most impressive case was a woman with a sore throat and a very high temperature (38˚C). Although I am glad I went with Maria Esther, I found that the work in the tent was my least favorite experience. I was very uncomfortable being surrounded by sick people, and even a little frightened that any one of them could have A(H1N1). Every uncovered sneezed made my skin crawl. I think what bothered me the most was not being able to see or identify what was wrong with each person. The deformity of a broken limb, or the change in skin from a second degree burn are problems that are easy to identify, easy to see. With sickness, the problem is microscopic, invisible. My sudden fear of the patients and their contagiousness was unsettling as I took their temperatures and weighed them.

But it is good that I went. Not only was I able to see the steps taken by a hospital when threatened by an epidemic, I took part in the process of prevention by working the triage tent. Hearing about the influenza daily in conversation, in the newspaper, and on TV made working the tent exciting, even if it was uncomfortable.

Thank you all for following my adventure. This blog has helped me to articulate my own perspective on the experience as it unfolded. I would not have done so much, critiqued as much, or been as proud and excited about my adventure had it not been for your support.

Thank you,

Ida Kruse

Week Five: Cultural Conflict and the Medical Field

2009-07-26T14:41:00.000-07:00

Hello again,

This last week has been both the most invigorating and the most exhausting I´ve spent in Otavalo. Every day of work this week I spent venturing to rural villages as part of the Rabies Vaccination Campaign that all of Ecuador is required to participate in this month. We vaccinated in Achupallas on Monday, Gualsaquì (same village as the clinic) on Tuesday, Urcusiqui on Wednesday, Cambugàn on Thursday and Muenala on Friday. Each day, we traveled farther from Otavalo. Muenala was a good hour and fifteen minutes away.

Although the bumpy class-four roads are not easy to take, especially when our chauffer bombs down them at 100 km per hour, I enjoy the thrill--also the spectacular views we get from these unpopulated areas: the mountains are steep and pierce the dramatically clouded skies. We have vaccinated around 350 dogs, Maria Esther and I still sharing the job of actually injecting.

The Conflict:

I was recently faced with a difficult situation, however, that reinforced what I had only been told about being involved in the medical field and simultaneously made a cultural conflict between María Esther and me come to a head. It is customary to ask for what you need here, whether it´s a favor, food, or money. I have been struggling with this custom ever since I arrived; being brought up as a New Englander, expecting little from others and doing my best to accommodate anyone who asks a favor of me. The countless bus fares and childcare I have committed to is not, in itself a problem, but it occasionally makes me feel like I´m being taken advantage of. It turns out this is just the nature of the culture here. Constantly asking for favors, and rarely getting compliance is the norm. Not knowing how to decline, I am guilty of fulfilling many of these favors. And so, I was asked yet another by María Esther a few days ago, but one I had not yet encountered: she wanted me to fill in for her at the clinic for the afternoon—and I declined.

Thinking about it afterwards, it was one of the best decisions I’ve made since I’ve been here. I declined for one main reason: I would be at the clinic alone and therefore in charge of the entire facility. In the slightest off chance that there was an emergency, I would be in charge. Although I am confident in my EMT training, I do not know what the protocols are in Ecuador and more importantly, I don´t know Quitchua, the language spoken by most of the people in Gualsaqui. What would I have done with a patient in critical condition that I couldn´t communicate with, in a country whose medical system I have only recently become aquainted with?

I learned as an EMT that the Good Samaritan Act (doing what you can to help in a situation as a citizen with little training) doesn´t apply to EMTs because we DO have that training. This is called the Scope of Practice. As an EMT basic, I have the smallest scope. By stepping out of your scope of practice, you could be held responsible for a death, even if you were just trying to save a life.

Being here on my own, responsible for my acts and decisions, I utilized this lesson when I told Marìa Esther I wouldn´t stay at the the clinic on my own. I am not equipped to run an entire medical facility in the case of an emergency. I would be stepping out of my scope of practice, potentially facing huge consequences--if not with the medical officials in Ecuador, with myself and my own guilt for accepting a responsibility I had no place in accepting, saying I could do what I actually could not. Paying bus fares is not what I want to do, but there is no consequence in doing this favor, other than having to do it again. For me, recognizing and declining a favor that seems simple enough but has huge implications with even bigger consequences was a big step: it represents an attention for medical protocol, a good habit for me and my intended career.

A few other exciting things I have experienced:

- Injecting a person (not a dog) for the first time: Ana stopped by the clinic and needed her monthly shot of Mesigyna (a form of birth control). Marìa Esther showed me the steps, and I successfully administered the drug.

- Attending a Panedería class (bread baking) at night a few times a week with María Elena, my host father, Segundo´s sister who runs a tiny store next to our house.

- Hiking around Laguna Mojanda, a beautiful lake at a shockingly high altitude for a lake that size. It is tucked way up in the mountains, right next to Fuja-Fuja, one of three peaks that surround Otavalo.

-Picked up a puppy at a Hacienda where we vaccinated in Achupallas to take home to the house. My family named it Aido (the masculine form of Ida).

With one week left, I am eager to see my family and friends again (and eat some good chocolate!) but also sad that my time here is winding down. It has been such an important and excellent experience for me, thank you all for your support and interest in my ventures.

-Ida

Week Four: Needle Experience and the Rabies Campaign

2009-07-19T16:32:00.000-07:00

Readers,

I could not have planned my trip together any better than it has turned out. The first week I spent observing, recovering from culture shock, and getting used to Spanish. The second week I started getting more involved at the clinic, saw several interesting injuries, and developed some skills. The third week I really started in on some hands-on experience and mastered several jobs at the clinic. Having just finished my fourth week, I have been introduced to a new kind of work. As I said, the introduction to a new skill could not have had more perfect timing.

This last week was the beginning of a dog vaccinating campaign, pulled together by the hospital in Otavalo and the staff in Gualsaqui. The rest of my time here will be spattered with days when the nurses, doctor and I will travel to various areas even more rural than Gualsaquì to vaccinate dogs and cats for rabies. Because of the limited staff, and the possible danger of being bitten, only María Esther and I are willing to actually inject the dogs with the medication. The others will record information about the families and their animals.

Although I was a little edgy about administering an injection myself for the first time, and I jumped at the first opportunity Marìa Esther gave me. It was a puppy, so I didn´t have to worry about any serious bites. The most important part of vaccinating these dogs is knowing how to tell the owners to hold their dog. It’s like a big hug around the head, so the dog is restricted from both seeing and biting you. The injection itself is nothing like what we people experience. Instead of a gentle prick, its more like a quick punch to the hindquarters, only with a needle instead of a fist. Mostly the dogs only yelp and cower, but occasionally there is a snarl, and once, a snap but at its owner, not me.

Although campaign days are long and exhausting, I really enjoy them. I get to travel even deeper into the heart of the country, and see homes and lifestyles very few outsiders have ever seen. Just as in Gualsaquì, Marìa Esther seems to know everyone, and their good humor and amiability towards us never loses its charm.

More next week,

Ida

Week Three: Drug Runner

2009-07-16T10:37:00.000-07:00

Hello again,

I have, over the last week or more, been slowly developing a slew of skills that make volunteering daily at the Subcentro de Salud a real job. But because there are three or fewer women running the health center at a time, what we do each day covers the entire medical spectrum. The following is a list of jobs I am now expected to do daily at the clinic.

Front desk: Includes taking patients’ information and locating their files, asking if they are at the clinic for ¨control o enfermedad¨ (vaccinations/birth control or sickness), and running patient histories from the patient intake room to the doctor´s office.

Computer Techy: I am also the official computer tech, and although I haven’t used Excel much, my technology skills far exceed those of Maria Ester. Together, we have revised and improved data on the computer, which often has duplicate patient names or ID numbers.

Patient Intake: After locating medical histories, I bring the patient (usually mother with her child) into a small room and record measurements, which includes blood pressure (for adults only), height, weight, temperature, and the circumference of the head (for children and babies only). These measurements, especially weight and temperature, are harder to take than they sound. I had to learn how to use two different old-fashioned scales, one for babies, the other for adults. The temperatures are taken with thermometers that have mercury in them, again the older version and not the digital kind I am familiar with. It brings to light what we might take for granted in the US with our updated medical technology.

When I am not doing one of these jobs, I am in the doctor´s office or the vaccination room where I continue to observe. The doctor, Viviane Bazante, examines a lot of babies and spends most of her time talking with parents about proper child care. A few days ago a set of twins came in. One was well over his proper weight, but the other was borderline malnourished. As the doctor was explaining this to the mother, she noticed that the mother was, in fact, nursing the healthy baby. The doctor immediately told her to switch, pointing out after how fiercely the smaller baby was nursing. Maria Ester is well-practiced in vaccinating children who react strongly, to needles and injections. She knows just how the mother needs to hold her child, and exactly how much time she has before the screaming begins.

Patient/Medic Relationships

One thing I have noticed over and over again is the importance of a good patient-medic relationship. Maria Ester knows practically everyone in Gualsaqui by name, and she can point out where they live and who their family members are. She talks with them about their lives and their troubles and listens to them carefully. Because of this, she has developed such a strong sense of trust with the village that they constantly ask for her and not the doctor. The doctora is the antithesis of Maria Ester. She is impatient, and speaks harshly to her patients in her office. She does not treat them as people, but rather a nuisance that gets in the way of her treatment and their sickness. As would be expected, her patients do not open up to her the way they do with Maria Ester, which is a huge disadvantage both to the patient and the doctor. Not only do patients not listen carefully to crucial instructions the doctor pelts at them, their glazed eyes and passive body language only frustrates the doctor more. Although it seems like common sense, juggling a patient´s feelings with treating their actual sickness is harder than it looks. Having seen both ends of the spectrum, it is clear to me that being a successful medical practitioner means caring not just about ¨solving¨ the sickness, but about who that person is as well, a skill Maria Ester has mastered in her last thirteen years as a practicing nurse.

Week Two: Child Burn Victim

2009-07-12T08:21:00.000-07:00

Hello all,

The following is a report called a SOAPnote that I learned how to write at SOLO, the month-long WEMT (wilderness emergency medical technician) course I took earlier this summer. It is meant to inform the hospital with critical information about the patient, the injury and what was done to help. For the purpose of this blog, I think it is also an appropriate way to summarize a case that I have experienced.

Subjective:

Patient: Laydi Israel Oyagata Tuquerres

Age: 15 months

Chief Complaint: Burns with excruciating pain and discomfort from upper thighs to lower back.

Signs/Symptoms: Skin was red and blackened in some areas. One large blister formed at the bottom, inner section of the right gluteal region. Pieces of a green plant (from mother’s cooking) was stuck to the skin in a few places.

Events: Patient´s mother described her daughter falling back into the fire where she was cooking on Sunday, June 27. She was brought into the clinic two days later, on Tuesday the 29th.

No known medications or allergies.

Objective:

The height and weight of the patient were not taken, nor were its vital signs.

Assessment:

First and mostly second degree burns that completely cover the patient´s buttocks, reaching down to the upper thighs and up to the lower back.

Plan:

1. Remove dead skin and clean thoroughly, applying antibiotic ointment and a light dry dressing.

2. Prescribe antibiotic treatment to prevent infection.

3. Prescribe pain medication

Summary:

The girl that came in two days after she was burned was already at a huge risk for infection. Her family was very poor and their hygiene was not good. The patient was not wearing shoes, and her feet and legs were smudged with dirt. I held her feet as a form of restriction to keep them from bumping her burn or the nurse, Legia, while she peeled the dead skin away from the site and popped the blisters. It is important to remember that second degree burns are one of the most painful injuries possible because all the nerve endings on the site are severely damaged but still functioning. The patient, who was still too young to communicate, could only scream. Her mother, who had her daughter lying across her lap for the procedure, seemed strangely unfazed by her daughter´s excruciating pain. After the patient was bandaged and wrapped up, the mother was instructed to bring her daughter in the next day to re-clean and re-bandage the burn.

The mother did not show up the next day. The doctor, the nurse (Maria Ester, my host), and I walked from the clinic to their house where we found that the mother had taken the bandages off her daughter. She was carrying her daughter with no covering over the site. It was open to bacteria and drying out.

Although Maria Ester convinced the woman to come back to the clinic to clean and rebandage her daughter, the doctor was not supportive, and after the patient had left the clinic once again, I was witness to a conflict that I think is a good example of two major medical perspectives that clash. Do you, as a medical practitioner, put yourself first, or your patient?

The conflict was this: Maria Ester treated the child because she was concerned for its health (the burn had the beginnings of infection already), but it wasn´t her place, as nurse, to administer that treatment. That should have been the doctor´s decision. The doctor did not want to treat the patient because the mother had removed the patient´s bandages, which was against her orders. By treating the child after this, the doctor would then be putting her own name and practice in jeopardy. She would then be taking responsibility for the mother´s unadvised actions that could lead to severe infection, and even death.

I learned that as an EMT, in emergency situations, you´re first concern should always be yourself, then the patient, so the doctor was right in refusing to treat the child, and in doing so refusing to take responsibility for the dangerous actions of the mother. But does that change when your patient is a child who can´t communicate or defend herself, and the parent is already under pressure from poverty, and uneducated on the dangers of infection? Do you jeopardize your name and practice and work outside of jurisdiction to help, or do you take care and do your best to advise the mother--something that clearly had not been effective before.

I am left with these questions to ask myself. What would I have done as a medical practitioner in the same situation? It remains a difficult decision that I´m sure no one involved in medicine ever wants to be faced with.

Several days later, I stopped by the house again, with Maria Ester. Although we didn´t see the child again, her older sister informed us that the patient had been taking her medication and was improving. The mother never brought her daughter back to the clinic.

Thanks again for your support,

Ida

Week One

2009-07-01T13:55:00.000-07:00

Greetings from Otavalo!

Thanks to Wheaton College´s Davis International Scholarship, last Tuesday through Thursday, I was able to make the trek from Burlington, Vermont to Otavalo, Ecuador, staying the night in Bogota, Columbia and Quito, Ecuador in transit to Otavalo.

I am living with a fantastic family here in Otavalo and taking the bus daily with my host mother, Maria Esther, to a clinic in a rural town, Gualsaqui.

Additionally, I completed my Wilderness Emergency Medical Training in June, and I hope to solidify what I have learned, practicing those skills and improving my medical Spanish.

After Wheaton, I intend to continue my study of medecine, becoming a Physician’s Assistant. Fluency in Spanish will help me reach a far greater population of patients.

A few fun highlights thus far in my trip-

-Eating cuy (guinea pig), a very special treat for Otavaleños

-Wathching the festivities of San Juan and the very old Incan holiday, Inti Raymi

-Saw a dead person for the first time

More soon,

Ida