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Attending at the Gateway to the Amazon

Shell, Ecuador, 27 Julio 2012

I'm sitting in my little casita (redundant? perhaps) listening to the rain fall on a quiet Friday afternoon.  The past few days have been gorgeous - comfortable, even bordering on cool, and mostly clear with very little rainfall up 'til now.  A couple of mornings and one evening it was clear enough to see the snow capped volcano that overlooks Shell.  Most of the time the mountain tops to the west are shrouded in clouds.  

I'm starting to get the hang of the routine here - rounds at the hospital at 7:30, clinic starting around 8:30, lunch from 12:30-ish to about 2:00 (siesta time! Gotta love Latin America! ), and afternoon clinic from 2:00-4:30 except Wed. and Fri. which are half days. So far my clinic days have been pretty manageable, though writing clinic notes in Spanish can be challenging (jargon doesn't translate so easily).  Most of my patients seem to have vague abdominal complaints - and most get a desparasitante and/or an antacid.  There have been a couple of interesting cases, though.  A young guy with a atrial septal defect (a hole in his heart) came in with an upper respiratory infection. I had just glanced over his chart before I examined him but gave it a more careful reading once I heard this gnarly murmur.  Basically you could put your stethoscope on any part of his body and hear it rumbling away.  He's in his 30s now, and no one mentioned hearing a murmur until a year ago, and they got an echo that diagnosed his problem.  He's doing well from a cardiac standpoint at this time, and refused surgery to repair the defect because he's afraid of the risk and afraid it won't cure him.  And Quito is a long way from his home.  I talked to him about the natural course of his disease - not good - and recommended he reconsider the surgery while he's healthy and before more damage is done.  Today I saw a 30-something guy complaining of abdominal pain and I noticed he has yellow eyeballs (scleral icterus).  When I asked him about it he said he's had it since he was 8. Nobody's looked into his liver function before.  Turns out he has indirect hyperbilirubinemia which is likely due to some congenital defect that never got picked up (and is likely relatively benign), but we'll look into it further next week when he comes back for an ultrasound.  

My call night on Tuesday wasn't too bad, several ER patients but no admissions. One woman came in with a crushed finger - a cement block fell on it and just destroyed her distal phalanx (the little bone that constitutes the end of your finger) and the fingertip was all busted up.  I called the surgeon to have a look because I wasn't too sure she wouldn't need an amputation.  But he sewed it back together, put her on antibiotics, and put a big ol' cast on her arm to keep her finger immobilized. Hopefully it'll heal without infection. Skin infections are very common in these parts, as is MRSA (which they call ORSA, for oxicillin).   There have been a few abscesses to drain this week, which I perversely enjoy.  

Another lady came in with kidney stones, there were a couple of constipated people, a kid with a viral infection, and then a pregnant woman with vaginal bleeding.  She was 8 weeks along by her last period, but had had an ultrasound last week that was off by about 3 weeks and didn't show any cardiac motion.  She was bleeding pretty heavily when I examined her and ultrasound confirmed the spontaneous abortion.  Such a cold clinical term for her heartbroken condition.  I'm grateful to be working with Ecuadorian residents in the hospital because I wanted to be very sure that it was clearly communicated to her that what happened was not her fault in any way and just part of the natural process of things.  She had very supportive family and friends with her, so I'm hopeful that she'll be okay in the long run.  

Speaking of working with residents, it's so weird to be less than a month out of residency and acting as an attending, supervising family medicine residents in a foreign country in a foreign tongue.  I have to concentrate so hard just to understand and process what's being said, that it's often difficult to stop to ask questions and offer any kind of insight.  It takes a lot of mental energy when you have to focus so hard all the time.  I end up asking for things to be repeated and explained, so I'm sure they think I'm an idiot.  I'm much smarter sounding in English, I promise, though I'm not sure how much help I am even then.  I think it's a difficult transition from resident to attending under the easiest of circumstances, but this definitely kicks up the level of difficulty another notch or two: second language + tropical diseases + limited resources + unfamiliar system/culture = fun times! (i.e. Humility 101). But it really is fun, mostly.  It's good to get out of my comfort zone...way out.  I need it. 

On a bit of a lighter note (maybe?), I was involved in 2 deliveries this week.  The Ecuadorians have some interesting methods when it comes to the management of labor and delivery. In many ways it's much more hands off, but in others it's more invasive. They use ultrasound evidence of a nuchal cord (umbilical cord around the neck) as an indication for c-section in many places.  The first delivery was a VBAC (vaginal birth after Caesarian) which I find nerve-wracking in the best of circumstances, much less in rural Ecuador.  But it went off without a hitch, once she figured out how to push.  The second was a first-time mom who had been in early labor for 3 days before she finally progressed to active labor.  But then she stalled out again and we gave her some pitocin (which doesn't always work here due to poor quality drugs).  It helped, but I was worried about uterine atony (which causes postpartum hemorrhage due to poor contraction of the uterus after delivery) because of her prolonged labor and the augmentation, and sure enough it happened.  Gave her some rectal cytotec and kept the pit going (glad we started it 'cause they don't routinely do IV's in OB patients here, instead giving IM pit) and she and baby did fine.  After that delivery, though, it really hit me that I was the responsible party here - no attending above me. Scary!

I've done a bit of exploring in town, mostly with one of the other visiting docs and his wife.  She is a firecracker!  Doesn't speak a word of Spanish, but while we were working all day she was exploring the town and the neighboring city.  Then in the evening she'd take us around to the best bakery and the best fruit stand and the tienda with the cutest little old lady.  It's been a lot of fun.  Shell itself isn't a big place, but it has an airport and a military base, and several mission compounds.  The streets are in a state of upheaval - dug up for repaving - and lined with lots of little shops and cafes, full of dogs and people of all ages.  I've mostly seen it after dark, since sunset is around 6:00 in these parts, but the town is pretty lively in the evenings - folks shopping and kids playing in the park.  Sadly, the folks I've been exploring with were only here for a week and headed out today.

Yesterday we went to the Nate Saint house, built by the first missionaries to the area in 1948. It's named for a missionary pilot who was one of the pioneers of mission aviation and modern South American missions.  He and 4 other missionaries were killed by members of the tribe they were trying to reach. The story of their deaths and their wives' and children's subsequent return to work among the very people who killed their family members made a huge impression on me as a kid. It was kinda surreal to stand in the very kitchen where they got the news, to see the hanger for the little yellow plane that flew out into the unexplored jungle when Shell was little more than a few houses and a dirt airstrip.  Pretty amazing. 

I'm on call this weekend, Sat. and Sun. That should prove interesting.  Eventually I'll get some time off in the daylight hours to get a better picture of where I am. And hopefully it'll be clear enough to see the peaks of the Andes again. 

Strange but True: The highest point in the world, if you count the distance from the center of the earth rather that from sea level, is Chimborazo, an Ecuadorian volcano in the Cordillera Occidental range of the Andes mountains.  It's 20,561 feet above sea level, but it's located on the earth's equatorial bulge (not a perfect sphere, this planet of ours).   



( 7 comments — Leave a comment )
Jul. 28th, 2012 12:43 am (UTC)
What a great slice of life entry! I really enjoyed reading about your physical surroundings and about working with patients.
Aug. 6th, 2012 11:44 pm (UTC)
Thanks so much for reading! :-)
(Deleted comment)
Aug. 6th, 2012 11:45 pm (UTC)
Thanks so much, dear! :-)
Jul. 28th, 2012 08:03 pm (UTC)
Wow! That sounds so awesome!

I work for an MD across the border, in Peru (she doesn't practice though, we do epi research). I totally feel you about the 2 hour lunches! How can I get those to catch on in the states, huh???
Aug. 6th, 2012 11:46 pm (UTC)
Thanks for reading!

Cool! What are y'all working on? We should really bring the Latin schedule to the US. Have to get on that...
Jul. 28th, 2012 09:53 pm (UTC)
I don't want to live on a bulge...I find that disconcerting!

Fancy you being the main (wo)man...but you really seem to have taken it in your stride; in charge, in Spanish, in less than ideal circumstances...and just think a couple of weeks ago you were holed up in your little house doing sweet FA! A recharging of your batteries to be able to hit the ground running... :O)
Aug. 6th, 2012 11:47 pm (UTC)
I guess it is a bit awkward to be on the bulge....

Thanks for your vote of confidence! It means alot. :-)
( 7 comments — Leave a comment )