No Vale la Pena, or Why a Chief of Medicine Aspires to Become a Taxi Driver

My first day in the Puyo clinic, and things were rather slow. This seems to be a pretty common theme in this tiny city of ~35,000, everyone claims that they prefer Puyo to Quito because it’s “mucho más tranquilo”. And although tranquilo is a kind of a false cognate (it translates more directly to “quiet” than to “tranquil”) I can’t help but feel that the connotations surrounding the word “tranquil” actually do the city better justice. It’s situated a on the edge of the Amazon rainforest in the crotch of the “Y” at the intersection between the lazily meandering Río Puyo and the larger Río Pastaza. Everyone seems to know each other, and the whole city is within walking distance.

And so, on a lazy day, my host doctor and I sat in his office chatting, but when I began to ask him about his life as a doctor he became noticeably agitated. He was eager to talk about his situation, but it didn’t make him very happy. There’s a sort of general unrest about the state of the government right now in Ecuador, but it seems that doctors have been acutely adversely affected. While the government has been commendably spending a ton of money to subsidize/promote quality education (although unfortunately the majority of the money has been going to top students/schools, rather than being more evenly distributed), there has been a burgeoning mistrust for medical professionals. Wages have plummeted as the boundaries for what constitutes medical malpractice have  broadened, and this creates quite the uncomfortable environment for the current Ecuadorian doctor.

Dr. Jimenez, general surgeon and chief of medicine at a small but high-end government-run hospital, makes under $22,000 per year. Granted, there is a lower cost of living in Ecuador than in the US, but it is apparent that the salary is not substantial enough. With the growing prevalence of lawsuits, skyrocketing lawyer fees, and the inherent need for doctors to be part of a global community/market, this is clearly not  an adequate salary for a doctor, let alone a chief of surgery. To stay on top of his craft, Dr. Jimenez explained to me how he studies for hours each night after he returns home. But even to do this, he’s got to buy the latest medical textbooks, which run upwards of $300.00 each. That’s a quarter of his monthly paycheck gone, just to try to stay up-to-date. It’s just not sustainable.

But the government has been reducing salaries while tightening regulations. Initially you might think that it’s a good thing to tighten the rules to regulate malpractice, but when doctors live in legitimate fear of being thrown in jail for a misdiagnosis or flawed treatment, it’s impossible for them to work at full efficiency.

It’s like you’re shooting a free throw at the end of a basketball game. There’s tons of pressure, and even the best shooters in the world are going to miss once in a great while. But for doctors, rather than maybe losing a basketball game, they get tossed in jail.

No vale la pena” (It’s just not worth the pain).

Dr. Jimenez sat pondering the state of medical affairs and eventually looked at me and said, “It’s just not worth it, I can’t keep this up for much longer. Once my kids are out of college, I’m going to try something new”. When I asked him what he was thinking, he responded, “I’ve put some thought in… think I’m going to become a taxi driver”.

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Emergency

Since my return to bustling Quito, I’ve been stationed in a local emergency room for 8 hours per day. In my first shift, I’m pretty sure I saw, learned, and did more than I had in the rest of my clinical experience combined. At 8:15am a patient walked in needing an electrocardiogram and my host, Doctor Cadena, bustled me over to watch an intern administer the test. At 9:00am another patient walked in needing an EKG and Dr. Cadena nudged me over and said ahora tú. My turn. A little surprised, I couldn’t help but grin at the opportunity and I was pleased to find that I remembered where all 10 electrodes went (which is definitely more of a product of my good teacher than of my good memory). At 10:00am a third patient walked in needing (you guessed it!) an EKG. We’ve all seen the sharp bumps and dips of a heartbeat, but I still had no idea what any of it meant. Maybe I just had a sneaking suspicion that doctors look at the mysterious charts, stroke their whiskers, grunting and nodding, and then pretend to have gleaned some important information. Either way, when the patient left, I asked Dr. Cadena to teach me how to understand the readouts. Next think I knew, I was shirtless, covered in electrodes, staring awkwardly at the ceiling as the little humming machine recorded all the electrical impulses whizzing about my chest. For some reason, the good doctor decided it’d be more fun for me to learn on my own readout. We spent the next couple hours poring over the little pink sheet, him pointing out the meanings in all the bumps and dives, me furiously scribbling notes in a jumbled mix of Spanish and English. In that (oft-interrupted) couple of hours, I managed to get the basics, and from that point forward, he has let me take the first glance at EKG readouts to tell him what I think.

This is not to paint the picture that the ER here is as quiet as a classroom—it’s far from it. While there is a decent amount of downtime, there are also a decent number of terrible injuries. Maybe that’s why the ER has begun to have a bit of a draw on me—there are such a variety of problems that could walk through that door, you kind of have to be prepared for anything. The most notable injury we saw that first day was a poor guy who had been struck in the leg with a friend’s machete as they worked to clear a section of jungle. He was hit just above the knee, his femur was cleanly chopped in two—just above the head—and a few layers of hamstring muscle and tendons was all that held the two pieces of leg together. During the ride to the hospital (he had to be carried part of the way in a horse-drawn cart), the leg had twisted around, so the two parts of the femur were disconnected, resting side-to-side instead of end-to-end. By some miracle, the guy was still conscious and reacted to some sharp prods in the toes—he still had the tendons and nerves connecting his brain to his foot and so should have been able to keep his leg. But there was still the slight problem of the lower half having twisted around on top of the upper half. Dr. Cadena ran down the hall and returned with a traumatologist friend. One held the thigh while the other pulled on the foot, twisting and scraping the bones back  into the proper orientation. After about 10 minutes of grunting and tugging (the poor patient had long since passed out from the pain by this point), his leg resembled a leg once more, and he was sent off to surgery. It looks like he’ll get to keep his leg. While all of the nurses, interns, and myself were busy cringing at the severity of the injury, the two doctors leapt right into action—grimly tugging and grinding bones together to try to save this poor guys leg. It was pretty incredible to watch, and I definitely gained a newfound respect for the both of them. But that’s not to say they were completely unfazed—just about every two hours every day since then, the traumatologist has poked his head in the door with a grin to ask if we had any more machete injuries he could help deal with.

One final note—on that first day, I saw four men come in with injuries sutained in motorcycle crashes.  Nothing was too serious, a couple broken bones and a strained knee-ligament… but it was definitely enough to make me reconsider my lifelong dream of buying a motorcycle so that I can ride around California like Tom Cruise in Top Gun. (Because of copyright issues that first clip couldn’t have the REAL soundtrack, so to get the full effect, mute the fist clip, and play this one in the background)

Side note: This scene, the motorcycle and the inexplicably 40-minute-long sunset, is probably about 96 percent of the reason I went to California for college.

Final final (random) note: I can honestly say that I’ve seen Adrian Peterson hit the gaps with less force than old Ecuadorian ladies do when they’re trying to squeeze on the trolley during rush hour traffic. I am very, very fed up with public transportation.

Quito

The first four week program in which I’m enrolled here in Ecuador is an Urban/Rural comparative observation. I spend two weeks here in Quito experiencing the city clinics, and then two weeks in tiny Chone to observe how Ecuadorian doctors overcome the challenges of rural healthcare provision. Because I only have two short weeks here in Quito, I’m desperate to experience all of the city before leaving. This is obviously impossible, and so each day consequently feels way too short. But because I feel the perpetual time-crunch, I have been packing as much as possible into every single day, and so it feels as if I’ve been in Quito for months already.

Upon arrival in the Quito airport, I was pleased to find that my Spanish skills hadn’t atrophied too badly in the 6 months since I had left Santiago, but there was still, unsurprisingly, quite a bit of initial confusion. In the crowded baggage claim area, I grabbed my bags and entered the nearby line to pass through customs. Only after I got some odd looks from the people in front of me did I take a sec to really look around… and I realized that I had somehow managed to insert myself into the front of a winding 100 yard line. Embarrassed, I risked a glance over my shoulder to gauge the reaction of the person in front of whom I had inserted myself… and found myself looking into the chest of a 6’5 bear of a guy. Luckily he appeared to be about as confused as I was, and after attempting to apologize and excuse myself in Spanish, realized he was an American. After talking for a few minutest, it turned out he was on my program. And living in my home stay. He actually ended up being my roommate and good friend, so I guess things worked out okay.

Sunday through Tuesday of that first week was a fairly intense cultural/language orientation, with 7 hours of daily Spanish class. I was pleased to realize that, although some of my peers had spent a significant time studying Spanish, I was one of the only students to have studied abroad before in a Spanish-speaking country,  and I was happy to discover that, while I’m a bit rusty with the technical details of the language, I have a much easier time than my peers actually conversing in Spanish. This has provided a nice balance as the majority of the others participating in CFHI are already in med school, and so when clinical rotations started last Wednesday, we were able to combine our various levels of language skills/medical knowledge to piece together just about everything going on in the surgeries/consults.

Unfortunately, after 7 hours of class/clinic, it’s difficult to find motivation to get out and explore the city, but frequent coffee shop stops help. And although I didn’t get half-way through my list of ‘must-sees’ around Quito, we were able to explore quite a bit of the city during that first week. I initially tried to keep to a “new food every day” routine, but after an unfortunate run-in with a pig intestine/blood soup, I decided the occasional hamburger is okay. My favorite spot in Quito so far has been the top of the Teleférico. The Teleférico is a cable car that snakes up one of the enormous mountains that rears up on the Western side of Quito. One of the vertical cable car ascents in the world, the Teleférico brings you from the base at 10,226 ft., all the way up to the peak at 12,943 ft. This vantage point, almost  4,000 feet above the city proper, affords the most incredible view of the city. Though I had previous read about Quito’s odd shape/location (9,350 feet of elevation, ~25 x 3 miles long, sprawling out less than one mile from latitude zero to fill the valley in between two majestic ranges of Andean peaks)  I didn’t really understand it all until I reached the peak of the Teleférico. The opposing range on the other edge of the valley felt like a stone’s throw away, rising up clearly while the city of Quito extended into the mist in either direction. On the mountain face away from the city, the peaks extended off into the clouds, poking out like  islands from the ocean. And as the sun set, the lights began twinkling on in Quito, sprawling out below us, and that was one of the most incredible views I have ever witnessed.

Cotopaxi over Quito valley Cloud Valley Quito at Night

Sorry these posts are so sporadic and lengthy! But as I said, I feel the time crunch so I don’t often write, but when I do… there’s a ton to say. If you enjoy, please click the “follow” button that pops op at the bottom right corner of the screen, and for more pictures, check out my flickr account by clicking on this link: http://www.flickr.com/photos/lukemayer/.

Thanks for reading!