How time flies, it is hard to believe my days in Munsieville will come to an end soon. We come and help building the new home every weekend (everyone was volunteering, so progress is slow, but tent and food are provided, so the family who lost their home is fine), today, the house is finally done, and I feel so happy and think it is a privilege to help people who live in shack. It is amazing that, with such limited resource, we build a high quality house in the shack with passion and faith. This house building event is a really good propagation for The Thoughtful Path, getting us closer to local people; even more, people are learning home safety knowledge from us (always lots of people watching us work).

Additionally, I have finalized the survey instrument, the guidebook for interviewer, code book, and data entry table. Betty drove me through the whole shack area to decide what sampling method to be used. Really exciting moment for me, because that’s the main reason why I am here- design a baseline survey collecting Munsieville Children’s information from as much respect as possible for future intervention use. Once I entered into Children’s Embassy, I meet up with volunteers who will conduct the survey, see those young, emotional, energetic “Munzy”, I brought them house by house to do pilot survey , teach them how to do interview, what need to concern, and leave them the guidebook just in case. Munsieville is such a beautiful place, I am not talking about its sight from eyes, obviously looks ugly and depressing, I am talking about something much much deeper. Look at those volunteers, the local director Betty and other staff, look at the caregivers and hub members, through their eyes, I can only see and feel the pure love and warmth from people in this community. More stories I hear the more tears I burst, those local volunteers love their community, and they try best to work with us, bring future to the next generation. Love working with them!

There was an exciting activity going on throughout the whole week! It is called Munzy Kids Holiday Club. This five-day long event gathered nearly 200 children from kids in the community, most of them are from shack area like Mshenguville and Mayibuye. Without education background of leadership, our Thoughtful Path director Betty, a local woman, is naturally an excellent leader. She ordered healthy food from local market, organized dozens of housewives making lunches for kids (food are different every day, included meat, veggies, and fruit), also summoned 20-ish high school/college students volunteering as teacher during the events. At the preparation meeting, those young teachers expressed all kinds of ideas of how to play with kids and make them happy. Sara, Abi, Dephane (other volunteers) and me just gave them a few suggestions on adding possible health education stuff into their entertaining ideas, they quickly figured them out and made some fun entertainments. For example, everyday there was a health topic, for Monday, topic is personal hygiene, teachers taught kids simple songs singing how to wash hands, how to use toothpaste. I was with one of the teacher all day, just in case the teacher didn’t express things clear. I am surprised that most kids can speak and understand English, and sometimes ask questions teachers can’t answer. A lovely girl kept asking me how I can escape from a firing housing if it has not door or window, and insisted this type of house exists.  

 

At a Wednesday night, we attended a leadership graduation ceremony. The Thoughtful Path created eight hubs promoting overall health status in Munsieville, and all hub leaders were in a leadership academy receiving 3 months long leadership training courses.  That night was an exciting moment for hub leaders; they were officially approved by Project HOPE UK and can work in field. Some of them I already know during the Munzy Kids Holiday Club, really looking forward to work with them!

    

Nov 24 2014

FGHL Yi He:

I was warmly welcomed by Mr. Paul Brooks, the executive director of Project HOPE UK and Ms. Betty Nkoana, the director of Thoughtful Path, Munsieville when I arrived in Johannesburg, South Africa. Before I came to South Africa, I learn from newspaper and other media source that although South Africa has the best economics condition in Africa continent, it has one of the highest HIV/AIDS prevalence as well as many other infectious diseases.

Munsieville is a small township in the Krugersdorp area in Gauteng Province, South Africa. Betty picked me up from airport in the afternoon and drove me to the Children’s Embassy, which is the official office of the Thoughtful Path, Munsieville. On the way to the Embassy, I was shocked by what I saw: abandoned factories, abandoned farmland, small town with few shops open; people were wandering around without purpose. All these things I witness were happened at places where are less than one hour driving distances from Capital- Johannesburg.

After one and half hour driving, finally we arrived in Munsieville, and meet other volunteers and staff in the embassy. I expressed my curiosity to Paul that it looks like housings near Children’s Embassy are not bad, as well as the surrounding area. Paul smiled and led me into shack area where I can’t see from roadside. There are countless shacks behind well-built government sponsored housing, children are playing with trashes on the unsurfaced road (if they can be called road), no electricity in home (people get angry if call them shacks), no firewood, no enough clothes to keep kids warm, everything here indicates that this community need urgent help.

Paul explained why Project HOPE UK chose this site to run the Thoughtful Path: Africa overall is a disadvantaged continent, South Africa is relatively better and considered as a model for other African countries, so if Project HOPE UK can run a successful program in South Africa, all other African countries can learn from this case, copy the model, modify it and make it native. For entire one year, Project HOPE investigated eight different communities across South Africa, and found out Munsieville is the one which need immediate intervention in respect of large numbers of vulnerable children in the community.

I was reading lots of documents regarding the history of Munsieville, Project HOPE UK, The Thoughtful Path, who they are and what they do. Although I am still in the middle of the reading, I am sure that what I will do here will definitely be one of the most memorable thing in my life. 

In my third week at Karapitiya Hospital I was introduced to Dr. Kumara, senior lecturer in Surgery. Participating in various surgical cases was what I was most looking forward to on my rotation in Sri Lanka. Walking into the OT I noticed it was quite a different set up from the operating rooms back in the states.  Patients were lined up on a bench right outside of the open theater doors with their medical chart in hand. Some patients were even curious enough to stand and watch the ongoing procedures from the doorway. On the other side of the patient bench was a make-shift PACU where the post-operative patients were still coming out of their anesthesia. Inside the operating theater, there were multiple procedures going on at the same time. In one corner of the room, a woman was having a lumpectomy under local anesthesia. In the center of the room, a man was under general anesthesia having an open cholecystectomy. Finally, off to the side of the room a woman was getting a carpal tunnel release.

As I was taking in the similarities and differences of the OT, one of the general surgeons asked me to scrub for a thyroidectomy. The case got underway and I was impressed by the speed and precision of the surgeon. Thyroidectomies are a very common procedure here in Sri Lanka and these surgeons perform so many each day, I’m sure they could do this procedure in their sleep. Following the procedure, I noted that the turnover time between cases is quite rapid. Turning over an OR at home takes a bit of time, but here, there is no time to waste. They have so many patients in need of surgery and not enough resources to do so.

One thing I found truly amazing about the Sri Lankans is their strength to overcome adversity. But more impressive is the way they do so without complaint. The patients waiting in the hallway of the theater could be there all day long, sometimes not having their surgery until 1 in the morning, but there was no complaining. I commented to one of the orthopaedic about how refreshing it was to have people be thankful for the help they are receiving instead of complaining about the wait time, or cosmetics of the scar, or the post-op pain, or even the food at the hospital! The surgeon told me that Sri Lankans are very accepting of their own problems and illnesses. Then he smiled, leaned in and said, “Sri Lankans don’t sue their physicians and that’s something you all have to worry about over there.” Sri Lankans understand that this is the life they were given and they will deal with it as best as they can. They do not blame physicians (or others) for their problems, but instead are grateful for the care they receive.

After a few orthopaedic surgeries, I stepped into the general surgery suite to watch an open cholecystectomy. Since we do these procedures laparoscopically in the states, it was a new operation to me. There is only one scope for the entire hospital so most all procedures that we would do laparoscopically at home are performed as an open procedure here. Similarly, the hospital does not have mesh implants for hernia repairs. Instead, I learned an old suturing technique to weave a meshwork of suture over the opening. Quite impressive and cost effective. As a global practitioner, I’ll need to be prepared to assist in surgeries with fewer resources and embrace both old and new techniques to achieve good end results. I am very grateful to have watched so many procedures and techniques that I won’t get to see (or rarely see) in my training in the US.

I also spend time with Dr. Kumara during his thyroid, vascular, and endoscopic clinics. In the thyroid and vascular clinics, I was surprised to see patients bring their own injections to Dr. Kumara. In the endoscopy clinic, I was stunned to see that patients were not sedated for upper endoscopies or colonoscopies. But once again, there are no resources available to take care of these patients post-procedure if they were to have an anesthetic so using a local anesthetic is the only feasible option.  

With that, we headed to meet up with two German medical students, also doing an elective clinical rotation. They were already in the casualty theater where we spent the rest of our day assisting in I&D’s, suturing small lacerations and bandaging head wounds. Overall, surgery in Sri Lanka very much surprised me. For the limited resources available, the shortage of qualified surgeons and the ever increasing number of patients in need of surgery, the surgeons here are very efficient with their time, skilled in technique and quite resourceful. We may have different ways of carrying out a procedure, but we all get the job done.

When I wasn’t in the OT, I was out in the community, learning more about the public health system, specifically the care of orphans and elderly. My colleagues and I have already been to a government run orphanage, and this week we wanted to see how the private orphanages compared. We visited an SOS Village, an Austrian run organization which hosts 12 children per home in 12 total homes on the property. Each “family” home consists of children aged 0-16 years brought in by the courts in cases of abuse or abandonment. The children are cared for by a “mother” in each home who cooks, cleans, and teaches the children valuable life lessons. These “mother’s” undergo years of training and a very intensive screening and selection process. The children still attend public schools like their peers, and return to the village to live a life as close to their peers as possible. It was wonderful to see an organization like this one, working so hard to give these children a rich and meaningful childhood.

We also made our way to a catholic-run elderly home where I had the pleasure of meeting an amazing woman who was blinded by the tsunami. She told us her story and how the sisters had found her on the streets, nearly dead, and brought her to the facility because she had no money, no family and no way to survive. The sisters were able to find a surgeon, who just this past year, performed an incredible surgery to restore her vision! She was able to see for the first time since 2004.

There were so many great stories from the folks at the elderly home, but what I liked most about the facility was that every resident helped out in any way they could. Some set the dining room tables for meals, others cleared dishes, or peeled vegetables, and some knitted bedding or doilies for the sisters to sell at the markets to bring in money for the home. Not everyone could pay, but no one was turned away.

With another fantastic week in the books, it’s hard to believe my time in Sri Lanka is coming to a close. I have learned so much in my short stay; it will be hard to leave. I am very grateful to have had this learning opportunity here in Sri Lanka and I hope that I may return here as a provider one day. 

 

After a long journey to the other side of the globe, I was finally in Sri Lanka. It was 1:00 am when I landed then I arrived at my lodging at 4:00am. I had 4 hours to sleep and be ready to work! When I woke up to monkeys howling and playing in the trees 20 feet away, I knew I would like this place.

I was excited and nervous to start my global health rotation at Karapitiya Teaching Hospital. Despite the fact that the University of Ruhuna Faculty of Medicine is conducted in English, there is still quite the language barrier with the Sri Lankan version of English and the amount of slang that we unknowingly use. Even the everyday medical language and abbreviations varies between the US and Sri Lanka. I wasn't sure how this would pan out when I arrived on the medicine ward.

Three of us are here in Sri Lanka from the Duke Physician Assistant Program. Since Duke University and the University of Ruhuna Faculty of Medicine have an established relationship in medicine and research, many of the professors and researchers were very welcoming to us. We met with Professor Ariyananda, the Senior Professor of Medicine, and he was quite excited to bring us to Grand Rounds and introduce us to his faculty and fellow consultants before we got started the next day.

The next day, we began clinical activities on the women's internal medicine ward, where we spent the week. We met with the Senior Registrar (similar to our Chief Resident) and she hurried us to the first patient to begin morning rounds. It was definitely intimidating on the first day while rounding with their equivalent of residents and attending.

After a few days, I was able to understand how the ward works to admit patients, complete investigations and diagnostic assessments and carry out a treatment plan. There are many similarities, but a greater number of differences between the US and the Sri Lankan inpatient wards. The overall appearance of the ward and staff, the admitting process itself, and the types of illness and their treatment protocols are notably unique.

When I first walked onto ward 11, I noticed there were more patients than beds, with some patients lining up with their belongings on the floor or with a make-shift mattress on the ground in the hallway. Some privacy is maintained with green curtain that can be drawn to a close, though this greatly reduces the air circulation and increases the already hot temperatures found on the ward.

Another distinct difference between the US and Sri Lankan hospitals is the admitting process. Patients can only be admitted to a ward on Casualty Day. While casualty typically means trauma or catastrophic event, here in Karapitiya Hospital, it simply means acute care. Each ward has its own Casualty Day, rotating every 5 days, so on any given day there is at least one medicine ward holding a Casualty Day. It's quite obvious which ward is having their day because the hallway outside the ward is lined with sick people waiting their turn to speak to a House Officer (intern). Because Sri Lanka has a public health system, and Karapitiya is a public teaching hospital, patients are first seen at their local community health clinic or rural hospital and if their illness is deemed to be beyond the capabilities of the small hospital or clinic, they are referred to the teaching hospital. The patient brings their diagnosis card to the House Officer- a laminated square paper with their personal identification information, their chief complaint, lab work if done, and treatment to date. The House Officer is the first to speak to the patient; they do a complete history and determine if they need to be examined or treated outpatient. If they are in need of an exam, they proceed to the line for the single admitting bed where the Junior House Office and/or Senior Registrar (residents) examine the patient. They will determine whether the patient gets assigned a bed or follows up with outpatient treatment. Unless the patients’ illnesses warrants a longer stay, most patients are typically released to outpatient care after 4 days- just in time for the next Casualty Day.

When admitted to the hospital, patients must bring their own medical record, clothing, toiletries, pillow and blankets. The hospital only provides one pillow case and one blanket which are typically used to cover the bed. Visitors are only allowed between 1-5pm, though one person is allowed to stay at all times.


Needless to say, patients who get admitted here are very ill. We have seen many patients with Dengue and Typhoid fever, severe heart murmurs, and strokes. Many of these illnesses are quite advanced at the time of initial evaluation. There was one patient who had such a loud heart murmur that it took me a minute to realize that it was her mitral valve making all that noise and not her breath sounds! I've never heard such a loud, distinct murmur in my training. When I felt for her apical pulse, it was as though her heart was punching my hand through her ribs. Thankfully, the patients here are accustomed to medical learners examining and questioning them every day, so it was nothing new for me to listen and palpate myself. In fact, these patients have a crew of consultants, house officers, registrars, medical students and nurses rounding on them daily.

Another interesting difference that struck me was the absence of beeping monitors and other technology on the wards. Vitals are obtained manually at regular intervals and charted on a paper above the patient's bed. There were no oxygen tanks hooked up for the COPD patients, no controls to adjust the hospital bed for comfort and certainly no television sets. The physicians and students are heavily reliant upon their physical exam skills. It was impressive how well these physicians could hear breath and heart sounds with all the background noise and conversations amongst providers. I hope I will be able to acquire this same level of competency in my physical exam!

I can already tell that I will learn a great deal here in Sri Lanka, both culturally and medically. I'm grateful to have already seen so many tropical diseases that are rare or non-existent in my hometown. This will certainly prove beneficial for future international aid work. Also, learning about the public health system and adapting to the difference in technology will allow me to be a better global practitioner. In the next few weeks, my colleagues and I will also participate in pediatrics, OB/Gyn, community medicine and surgery. There will be many interesting patients and experiences to come!

I had plenty of time to contemplate all that I had seen during 12 hours of travel back home from a medical mission trip to Georgetown, Guyana. I had just spent three weeks working in the Accident & Emergency (A&E) department at Georgetown Public Hospital and using my training as an Emergency Medicine resident in the United States to help teach new ER doctors core material such as EKG reading, airway management, and the approach to shortness of breath and chest pain. I had not realized when I arrived how much of my time would be dedicated to sitting in the metaphorical trenches and caring directly for patients coming to the A&E. I was prepared for a foreign experience in a distant land, but instead I found myself right in my element.

The minute-to-minute practice of medicine was in Georgetown was very similar to what I was used to; see as many patients as possible, gather all the information you can, make a decision—often instinctual—to admit a patient or treat them at home. One important difference, however, is that in the United States it is easy to get caught up in which hospital has a trauma center, who has immediate cardiac catheterization capabilities, and how long it might take to get a specialized MRI or exotic blood test; these distinctions do not exist in Georgetown, and as a physician I got back to basics. In medical school what we really learn is how to interact with and assess a patient; how to sit, what to ask and how to listen, where to push and prod, how to translate the patient’s presentation into terms of anatomy and disease process, and how to offer comfort. These remain the most useful tools in a physician’s arsenal and are the foundation of all medical care no matter how many elaborate adjunctive capabilities you have at your disposal.

When a concerned mother presented her coughing infant for evaluation, rather than immediately ordering an expensive antibody test for respiratory viruses, I got to be a doctor. Does the patient look ill, or does she look like a normal baby who happens to be coughing? How long had she been sick, did she have a fever, did she have any prior medical problems? What do her lungs sound like? While I was thinking about the possibilities, I used the moment to reassure the mother how well her baby looked, and her look of relief reminded me why my job can be so gratifying. Ultimately the baby checked out fine, required no testing, and the decision to discharge her was as practical as it was scientific—her mother was reliable, lived nearby, and would return if the situation worsened. In this case, practicing medicine meant relieving anxiety and educating a family member, at the cost of merely a few minutes of focused attention and interaction.

One early morning, a young man was brought in by his family members for confusion and shortness of breath. Sitting in a wheelchair, he was having difficulty concentrating on my questions and panting as if he had just finished a marathon. Virtually any cause of confusion and shortness of breath can be diagnosed for the price of a couple CT scans, a blood gas analysis, full panel of labs, possibly a cardiology consult and stress test, maybe an ultrasound or MRI. If resources were unlimited, one could simply check all the boxes on an order sheet at home if so inclined. Instead, we started with the basics—looking and listening. This shortness of breath had not started suddenly. He had no pain. He was not blue from lack of oxygen. He looked very dehydrated. Despite his rapid rate of breathing, his lungs sounded clear and he was not sucking in at the ribs or working hard to breath through fluid or inflammation in the airways. In medical school we learned about “Kussmaul” respirations, a pattern of deep breathing meant to get rid of acids in the blood, usually from undiagnosed diabetes. We did have a glucose meter on hand, and it turned out his blood sugar was critically elevated, proving the diagnosis. The treatment is simple, and he improved over several hours with IV fluids and insulin. In this case, practicing medicine meant a thorough history and physical examination, and the cost of one glucose check and widely available basic medications.

In a blur of activity, orderlies whipped into the A&E with a woman found unconscious at home. She was limp, unresponsive, snoring and gurgling through her oral secretions. In this situation, protecting the patient’s airway with a breathing tube is essential to prevent secretions from draining into the lungs and getting infected. There is no fancy test required, but getting the tube in place can be difficult and can require specialized equipment. At my home institution, a cutting edge machine with a fiberoptic camera at the tip and a high definition screen can be used to look around the patient’s tongue and place the breathing tube through the vocal cords. In this A&E we had one basic device, and with it the resident was having difficulty passing the tube as the patient’s oxygen dropped lower and lower. Even in this extreme case, going back to the basics proved life saving. As we learn in our airway courses, what saves lives initially is not placing a breathing tube, but rather simply ventilating the patient with a bag and a facemask, by holding the jaw just so. Employing this technique brought the patient’s oxygen back up and gave us time to change the patient’s position, the size of the breathing tube, the height and angle of the bed, and optimize the conditions for the procedure. When the situation had calmed down, we took a slow, deliberate look for the vocal cords and passed the tube successfully.

I came away from these clinical scenarios with a new appreciation for basic medicine. In the era of whole body CT scans, unlimited lab analysis, and myriad medical gadgets, the fall back is always our own eyes, ears, and hands. Forming a therapeutic bond with a patient, asking the right questions, searching for the right clues, combining instinct and basic life support skills, and caring for patients with compassion are principals that know no borders.

As I was packing for my first international medical trip to Guyana, South America, my wandering mind conjured image after image of third-world medicine based on popular notions and dramatic stories I have heard over the years. I imagined a row of soiled cots where emaciated children without IV access spent their final hours. I pictured a sweltering tent full of tuberculosis patients collectively coughing up blood; or a bathroom-sized emergency department packed with fever-stricken, jaundiced, indigenous peoples dying of AIDS, malaria, and other ailments while overwhelmed healthcare workers looked the other way out of emotional self-preservation because they had nothing to offer. As described to me by some physicians who had been there in recent years, some of these were features specific to the hospital I was heading to in the capital city of Georgetown.

I am delighted to tell you how antiquated and cynical my preconceived notions had been.

On my very first day in the Accident and Emergency Department (A&E), my first patient did not have AIDS or malaria or tuberculosis; he had hypertension and diabetes, and came in for chest pain. I have seen this exact patient many times in my own tertiary hospital in the States! I caught myself thinking perhaps my view of international medicine was a bit narrow. But, I thought, we probably wouldn’t have the equipment to diagnose him, and even then certainly we would have no treatment to offer. Wrong again. A junior resident from the brand new graduate training program in Emergency Medicine appeared beside me and handed me an EKG. “Inferior wall MI (heart attack). He’s gotten fluids, aspirin, oxygen, and morphine. Holding the nitro. We’re waiting for his portable chest x-ray so we can start heparin, and the admitting team is on their way down to evaluate him for streptokinase (clot busting medication).” Incredible! His care was nearly equivalent to that in thousands of small hospitals across the United States.

My very next patient was brought in on a gurney in full cardiac arrest for unknown reasons. Far from looking the other way, a team of three physicians including myself and four nurses started CPR, provided oxygen and ventilation, established two IVs, started fluids, checked his blood sugar, attached a cardiac monitor, gave epinephrine and sodium bicarbonate, and attempted defibrillation before finally pronouncing him dead. This was fully consistent with my own training.

Time and time again, I was surprised and humbled by the world-class care being delivered in this developing nation, from the availability of a neurosurgery consultation for head trauma, to blood cultures and antibiotics for septic shock, to the text book intubation of a comatose stroke patient (there was an available ventilator in the ICU), to the use of an “asthma room” for wheezing asthmatics receiving inhaled medications, oral steroids, and intravenous magnesium just like we would do back home. To be sure, this is not always the case, and there are countless places in the developing world with no medical resources at all, but the quality of care delivered in this public hospital in one of the poorest western nations is remarkable. I believe this is a great example of the success and power of international health efforts.

In Georgetown, an American team of Emergency Medicine residents and faculty, of which I am a member, are staying in a compound called Project Dawn, an international collaboration which houses teams of physicians and healthcare workers from the United States, Canada, Scotland, India, and many other countries around the world year-round. Like ours, these teams spend intensive time in the city helping provide direct patient care, teaching at the bedside, and setting up infrastructure and training programs. This, combined with the ambition of the local physicians who have trained in Guyana as well as places like Canada, the US, Cuba, India, and Europe, is a recipe for excellent patient care.

I am particularly proud of my home institution, Vanderbilt University and its Department of Emergency Medicine, and our involvement here. Within the last few years, we have had the privilege of assisting the Georgetown Public Hospital Corporation create a self-sufficient Emergency Medicine residency program to train new classes of emergency physicians who are specially trained in resuscitation and acute care of a wide variety of problems, from cardiac arrest to broken bones to childbirth to infections and trauma. As we’ve seen in the US, this training benefits patients by relieving the surgeons and family practitioners who typically cover emergency rooms but may not be well versed in the care of medical problems outside their usual scope of practice.

As my American colleagues and I led a didactic conference last week with the new residents, I witnessed with awe the geographical boundaries and disparities of health care dissolve. Together we interpreted the mysterious subtleties of EKGs, discussed strategies for resuscitation of shock, airway management, differentiating types of bleeds around the brain on CT scan. The local residents brought their own real-life cases for a conference, calling on each other to think though work-up and treatment of various life-threatening conditions. These residents would be as at home in our conference room in Tennessee as we are in theirs.

The far-reaching positive impact of international health efforts are all around me, and it is truly remarkable. Of course, none of this is possible without the enthusiasm and dedication of a well-educated and well-trained Guyanese health care force. I feel very honored to be part of something so inspirational, and I urge readers to continue to support international health efforts, as the gains from these investments are tangible and quite amazing to behold.

 

H. would probably be at the top of her class no matter where she went to medical school.  Like most of the Ecuadorian medical students I have had the privilege of working with she is curious, dedicated, and focused.   She attends a prestigious medical school and has had the opportunity to complete clinical rotations at some of the largest hospitals in Cuenca and Quito.  Her dream is to study internal medicine.  Part of her curriculum includes a scholarly work.  This is especially important in Ecuador because the most valuable research to a physician anywhere in the world is that which is conducted on a population similar to her patients.  For example, in Ecuador there is a very high rate of gastric cancer but no one knows why.  This is true of the entire Andean region and it is assumed that it is due to an unknown environmental exposure but more research is necessary.  If an Ecuadorian doctor wants to help her patients prevent and survive this common devastating disease, she needs to know its causes and the efficacy of available treatments within her target population.  However, H.’s attempts to come up with original research were severely hampered by a lack of resources because her school could not afford the expensive institutional subscriptions to databases that we U.S. medical students take for granted.  Her instructors teach with many of the same methods I experienced in the U.S., namely intense questioning and brief lectures.  The difference is that, while I can access the latest in updated medical information with the touch of a keyboard on my smart phone, laptop, or tablet, she purchases photocopied textbooks.  In the U.S. my professors have often commented on how medicine is constantly changing and that the pace of change has accelerated significantly in the last couple of decades.  Instead of memorizing massive textbooks as our predecessors did, we are expected to find our information in constantly updated online resources, review articles, meta-analyses, and medical journals.  H. is lucky because she happens to be fluent in Spanish and English making articles accessible to her, if only she could get a hold of them.  While my interactions with H. and other Ecuadorian medical students greatly enriched all of our education, I think that simply providing them access to online medical resources would do even more.  Access to information is changing our planet but far too much medical research remains locked within electronic libraries with expensive passwords.  

Valantina is the granddaughter of my host family in Riobamaba.  The family is middle class and well educated, both parents having attended university.  As is common in Ecuador, Valantina’s parents started having children very young and continue living with their parents.  Before the recent death of my host mother’s mother, four generations had lived in the house.  Valantina is 9 months old and the delight of the entire family.  As you will note in the pictures she is generally healthy and adorable.  There are some things that her family does that help her grow and stay healthy.  Though her mother is in college full time, Valantina has never received formula.  Her mother frequently breastfeeds at the table or in public places.  This is common practice in this provincial capital and during the Easter parade, there were women openly feeding their children as they marched through downtown, an unlikely sight in the U.S.  After I moved to Cuenca I noticed that more babies were drinking formula from bottles.  Multiple people explained that this as a consequence of wealth.  Cuenca is more affluent then Riobamba and formula is considered proof of economic security, an unhealthy trend.  I was fascinated by these changes because they seemed opposite to what I have observed in the U.S. where it is often well educated, more privileged women who tend to have the control over their lives that allows them to breastfeed. 

I spent a significant amount of time working at the ‘foundation’.  This is a hospital funded mostly by a wealthy family that owns home appliance stores.  People pay minimal fees (3-12 dollars for an ER visit) to receive care.  The hospital has a well respected neonatal intensive care unit as well at both inpatient and outpatient services for women and children.  One case in particular stuck with me.  A woman came in after a failed home delivery.  She had delivered her first 6 children at home but subsequently lost 2 of them to respiratory illness within the first 2 months of life.  She had been laboring since the day before and kept saying, ‘I can’t, I can’t’.  She knew something was wrong and that this did not feel like her other deliveries.  We immediately took her to the back OR where women delivered.  While the patients labored in shared rooms and walked the halls with their husbands and families, for deliveries they were wheeled back to the OR where they were placed in stirrups and usually received episiotomies (a procedure no longer routinely practiced in developed nations).  This patient kept begging for her husband and went so far as to crawl off the table and walk toward the door with her IV in tow.  Someone finally went to get him and dress him in the surgical garb required in this area.  Almost immediately she calmed down and started following the doctors instructions.  They had her stand next to the operating table and try to deliver in this more traditional position, without success.  Eventually she was taken to surgery where a baby was born.  He subsequently spent weeks in the NICU until he was released to his family.  The fact that this child and his mother were able to survive certainly makes this a success story.  However, I learned many lessons for my future practice.  For example, patients are better able to work with the medical staff if they feel safe.  It can be inconvenient to have family around, but their presence can add a calm that makes medical efforts much more effective.  Also, patients often tell us what they need.  This patient had delivered many babies by herself and in retrospect, it was very unlikely that she would deliver simply because of a change in venue.  Perhaps we should have immediately taken her to c-section.  One thing that caused the doctors to delay this decision was that the patient is charged more money for surgery and this can be a large burden.   However, the NICU is also expensive and perhaps the baby would have been in better health when born if the surgery had not been delayed.