May 18th, 2011

It’s been a while since I had

1) time to sit down and write, and

2) something interesting to write about. 

I’m not going to guarantee anything interesting in today’s post, but I do have some time…

We are now in Ecuador, our third of nine countries on this trip.  We arrived into port on Saturday, May 14^th, and are actually docked at the pier in Manta.  This means no waiting for hospitality boats to take us to the shore.  Instead, we wait for hospitality buses to take us to the medical sites.  Manta is a fairly large town, and is quite industrialized when compared to our previous clinic sites.  At the end of this mission we will have our first of two liberty stops here, and there are plenty of hotels, restaurants, and bars within a short taxi ride of the pier.  This is a topic of much conversation and excitement, let me tell you.

On our first day here, I was on shore at the surgical screening site, which was a local free clinic.  It was a Saturday, so the clinic would have been closed, but opened for our mission.  This was the first time we’ve had an actual medical facility for our medical mission – so we had sinks, exam tables, chairs, desks, and electricity in each exam room.  The medicine consultant (me) also happened to have one of the two exam rooms with air conditioning – and it quickly became the “I-have-a-quick-question-but-I’m-going-to-drag-it-out-and-actually-it’s-not-really-a-question-I-just-came-to-cool-off” room.  I re-learned how to play poker and looked at a few EKGs, but I felt superfluous. 

On Sunday, I was put to work at one of our MEDCAPS sites, in Rocafuerta, a 50-minute bus ride from the pier.  On that bus ride, I fell in love with Ecuador.  While the pier and the surgical site are located in downtown Manta, Rocafuerta is in the countryside and the route to get there is really scenic.  The ceibo tree is (apparently) native to Ecuador and is beautiful – I have pictures but you should google it to see for yourself.  During the bus ride that day, I put on my headphones, listened to an old Kidd Kraddick in the Morning podcast, and drank my Starbucks frappuccino on ice while I enjoyed the scenery.  As far as this mission goes, it was about as perfect a morning as you could ask for. 

When we arrived at the MEDCAPS (medical civil action program) site, I was again pleasantly surprised.  The site was a local school (again closed, as it was Sunday), and it was located in a beautiful town square, with a gorgeous chapel, several restaurants, and a few stores.  The school was much nicer than the one I described in Peru – the classrooms were still sparse but the architecture helped make up for it.  The floors were tiled with bright-colored geometric shapes, the walls were a bright yellow (but not obnoxious yellow, more of a marigold color), and the classrooms were all open-air – no windows.  Turns out they get 0.2cm of rain per month here, so keeping dry is not an issue.  Windows would have been nice, though, for the mosquitoes, which kept taunting us by landing and sticking around on our permethrin-pretreated uniforms.  Our preventive medicine guy keeps telling us they are dying a slow, painful death when they do that, but still.  Come on.

The rest of my day at the Rocafuerta site was great.  The patients were all wonderful, the translators did a fantastic job, and the flow was smooth.  We were permitted to leave the school for lunch, which never happens.  As I left with another internist, we joked that we felt like we were in Shawshank Redemption – the freedom was that sweet.  Not wanting to push the limit, we ate at the first restaurant we came to.  We had encebollado, supposedly the most popular dish on the Ecuadoran coast, which is basically a soup broth with large chunks of fish, onions, cilantro, and lime.  So far, 3 days out and I’m ok…  We each had a bowl of soup, some plantain chips, and a bottled soda (I had Inca Cola – a bright yellow Peruvian soda that smells like bubble gum and tastes like cream soda).  Our total, for the 2 of us, was $2.80.  When we left a tip, the owner chased us into the street to tell us we had accidentally left money.  I’m really hoping the rest of the places in Ecuador are similar – liberty will be a lot of fun.

I was so enamored with Ecuador after my day at Rocafuerta.  I should have stopped there (not that I had a choice).  The next day, Monday, I went to a different MEDCAPS site, this time at Montecristi.  Montecristi is apparently famous for their Panama hats.  It is another scenic town, located up a tremendous hill.  The school that we took over for the mission was not surrounded by civilization – it was surrounded by hills.  There was no breeze.  To get the site, patients had to climb (walk) up steep roads for miles – usually carrying their kids (and sometimes their parents) or not feeling well.  Many of them arrived at 4am or earlier, and the clinic didn’t open until 8am or so.  Once we opened the doors, we had a set number of patients we could see, and there were many more than that waiting in line already.  You can imagine that the tension in the line outside the site was high, and there have been riots every day that site has been open. 

Some days things just seem to go well, and other days not so well.  This was one of those “not so well” days.  My translator, while nice, was not great at following instructions or directing the patient interview.  The patients – hot, sweaty, and sick – were anxious to talk about their problems and didn’t want to leave.  As opposed to other sites, where the complaints were usually straightforward and easy to fix (UTI? Here are your antibiotics, have a nice day), it seemed like every patient at Montecristi had fatigue, weight loss, abdominal pain, and trouble breathing.  I was definitely suffering from “compassion fatigue” – which, as you can probably figure out, means I was losing my ability to care.

That day, I ate lunch on the second floor of the school and looked out at the valleys below us, as well as the hundreds of patients in the school courtyard still waiting to be seen, and tried to muster up some compassion to get me through the afternoon – after that, I had 2 scheduled days off, so that helped.  One of my first patients after lunch was one of the saddest cases I’ve seen in a while.  I’m pretty sure he had Huntington’s disease, a progressive, invariably fatal neurological disorder that can hit anytime in life with symptoms of involuntary limb movements and tremors progressing to spasticity and dementia.  This patient was 45, and came in with his wife.  He could barely walk and leaned on her with most of his weight just to make it into the room.  His entire right arm moved involuntarily around his head and body, almost like he was doing stretching exercises.  His left arm had a substantial resting tremor.  His speech was extremely limited, although he was able to talk in 2-3 word sentences.  According to his wife, this had all started acutely 2 months ago.  By her report, he had undergone an MRI which was “normal.”  Unfortunately, even in the US, there is no treatment for Huntington’s, but I was able to get him a wheelchair and some physical therapy education.  He was ecstatic, and so thankful.  He was able to operate the wheelchair and I think we really made a difference in his quality of life.  The sad part is that it will inevitably progress and he will likely die from this disease – as will all of his children, at some point, as it is a disease that is inherited (in an autosomal dominant fashion, for all you medical readers).  I didn’t tell him that.  I’m not sure if that was the right decision.

Anyway, after seeing that patient, my ability to care was rejuvenated.  The rest of the day went better and I have recovered somewhat over the last 2 days back on the ship.  As it turns out, I won’t be going out again until Saturday, so I’ll have more time to recoup.

Not to totally switch topics, but I realized that I never wrote about the week of miracles on the ship.  It was Easter week, interestingly.  Here’s the scenario.  Prior to that time, we had been instructed that PT gear was only to be worn during actual PT, and going to and from the gym.  And while Navy personnel could wear civilian PT gear, our Air Force commander had decreed that only the Air Force PT uniform was authorized.  We had all bitterly complained (given the ship’s laundry turnaround time and the overall unattractiveness of the AF PT uniform), to no avail.  Then, for some unknown reason, on Easter Sunday, we received an email from our commander authorizing civilian PT gear for PT – we were elated!  It was an Easter miracle.  The next day, the ship’s commander (known as the Commodore) set the policy that PT gear could be worn outside on the flight deck, for reading or just hanging out.  So, instead of being in full ABUs outside, we could wear normal-looking shorts and t-shirts.  Miracle #2.  THEN, later in the week, I was shopping in the ship “store” (which is 2 aisles wide and 20 feet long), when I spotted, out of the corner of my eye, a cooler/ refrigerator.  Inside were several dozen bottles of Starbucks frappuccinos – coffee, mocha, and vanilla flavor.  I think I’ve lamented enough about the coffee here for you to understand my excitement at this discovery.  For those who don’t know, I’m not even a huge Starbucks fan.  However, it so vastly exceeds the alternative coffee option that I immediately bought 8 bottles.  From that point on, I was back to my normal, functional self in the morning.  Miracle #3.  These may sound like small events, but trust me.  They are evidence of a higher power. =)