Looking back on my CFHI experience

Part of the CFHI group

I had a really amazing time on this CFHI Urban Rural Health comparative in Ecuador.  I think the Spanish classes were great and helped me learn more medical Spanish.   However, I learned much of the language and culture by just living in the country with host families and rotating through clinics and hospitals with various doctors.  I also got a chance to see and learn about many things that I probably would not have seen elsewhere in the US—like the case of Dengue and various cases of parasites.  As I come into my last few years of school, I am starting to pick which specialty areas I would like to practice in as a Naturopathic Physician.  This program helped me realize that I really like Primary Care , Pediatrics, and Neonatology.  I really would like to work at an integrative practice or clinic with Medical Doctors, Chiropractors, and other specialties.  Prevention has always been what I wanted to work with and educating people on how to take care of themselves and their family plays a big role in prevention.  Two of the six principles in Naturopathic Medicine are Doctor as Teacher and Prevention.  At the same time, in order to prevent illness you need to know where your patients are at in their life journey and their access to resources.  Amazingly, this program showed me that even though resources and money are lacking, one can be very creative in using what they do have to benefit patients.  The health care provided to the patients in Quito and Chone was actually good given the lack of resources.   Sometimes I felt that they didn’t use resources right there available to them.  In Naturopathic Medicine we learn about botanical and herbal medicine.  There were many plants there that could be utilized as medicine to help patients so the doctors would not have to rotate the same pharmaceutical drugs for different cases that

walk in the door.  But medical doctors do not really learn about botanical medicine there.  Also better water system could be established so that there would not be as much diarrhea and malnutrition.

Aimee, Dra. Diaz, and Rachelle

But who has the money to build it?  So, I can definitely say this trip inspired and motivated me.  I will end by saying the quote that has been traveling through my mind since the trip:  “If not me, then who?  If not now, then when?”

Think about it.

The Hospital in Chone

Hospital in Chone, Ecuador

In Chone we work (or shadow) doctors at the government hospital called Hospital Civil.  We shadow Dra. Matilde Diaz and she and the other doctors we have encountered are very friendly.  Some of them know a little English but everything is done in Spanish.  The doctors ask us questions about how we would treat the patients.  We often do rounds in Pediatrics in the morning and then go to other departments after that and in the evening shift.  Dra. Diaz allows us to do some physical exams so I got a chance to hear the lungs of kids with bronchitis and asthma.  I also saw kids with parasites, worms, and a few cases of appendicitis.  We also got a chance to shadow Dra. Diaz as she did consults on another floor that had a clinic.  In the clinic was interesting because I got a chance to listen to people’s stories since most of them came in for follow-ups.  All of the patients are really nice and grateful.  We had 2 brothers come back in after their appointment to give us kisses and hugs.  Then a tall 14 year old girl chatted me up about my braided hair.  She thought I was from the coast.  After the visit she gave us a hug and kiss too.   For this to be a rural area with little resources, the hospital is very organized.  The doctors all wear the same formal attire and the secretaries also wear the same type of uniform.  Residents have a little more leisure in their dress I guess since they constantly go from scrubs to clothes for rounds.  I did notice that the Pediatric floor had no air conditioner.  And the hall was  locked off to the public, only open at certain times during the day for visiting fathers and relatives.  Also, the power would just go off once in a while and no one would really pay attention to it because it was typical I guess.  I just wondered how the rest of the hospital survived in such power outages—especially with babies and adults on ventilation systems.  Maybe the power outage did not occur in those areas.

Me holding the second baby I got to witness being born.

A few days we were in the Neonatal area.  We had to wear scrubs, bonnets, and footies for this area.  Once again, the doctors were very friendly and chatty (we tend to get questions about if we are single, married, our age, what our profession is, etc.).   We saw 6 cute little premature babies, all with various lung issues and one with jaundice but he was full term.  As we followed the awesome resident, he would go from room to room doing procedures on the babies—mostly a suction procedure to get the fluid out of their lungs.  I assisted in one procedure and it kind of freaked me out because the baby’s SpO2 went way low during the procedure and took a long time to come back up.  I didn’t know if I did something wrong or what. At first the resident looked a little worried but he didn’t scream at me or anything.  He thanked me for my help.  He and the nurse got the baby stable again and said that it was fine…then the resident proceeded to sing the “Joy, joy, joy” song.  I also got a chance to see a natural vaginal birth, a partial hysterectomy, and a C-section.  It was a great day!!  When we got ready to leave, the resident we had been shadowing act like he was crying.  I think he liked the company because he had been on since the day before and had to be there till the next morning.  Crazy resident hours!  So yea, neonates and ob/gyn was a good shift!  I definitely want to go back.

Hysterectomy--removed uterus with fibroids in it.

One day, we did a Surgical rotation and I must say, surgery is not my thing.  The dynamics was different on that floor.  It seemed like most anesthesia was regional so the patients were awake during it and could hear the surgeons.  Surgeons were ready to cut and did not really communicate with the patient.  We saw the removal of a lipoma from the inferior patella and it didn’t seem like the doctor was thorough with making sure they removed it all.  The doctor added a drain tube, stitched up the leg and then cast the leg (not sure why the cast).  We  also saw 2 hernias being repaired.  Then the last surgery we saw was the repair of a broken femur.  There was a lot of tugging and pulling by the 4 surgeons on this patient’s leg and then discussion about the best angle to drill

for the placement of the screws.  It was all a bit much for me so I left after that.

We did an ER rotation a couple of times and that was always eventful.  The ER was an interesting set up.  The people would wait in the hallway which had seats.  The room we were in had 4 tables, 1 patient chair, 1 desk for the doctor, 2 cabinets for supplies and 1 cart that also had supplies on it.  The room may have been 15 ft X 15 ft.  There was another room behind a gate where they put patients for observation (I think over night observation).  Patients would come in and explain to the doctor what was wrong.  He would do a very quick, general physical exam and then start writing 3-4 scripts.  The patient’s escort (usually a friend or family member that came with them) would go to the Farmacia in the building and purchase what was needed and bring the items back in to the doctor.  One of the two nurses would administer the medicine (usually injection or IV).  After a few minutes (dependent on the treatment) the patient would be released with ~3 more scripts.  The doctor told us they pretty much have 3-4 drugs to choose from to give to the patients.  There were a lot of pain medications prescribed and anti-nausea/anti-emetics given to a range of patients.  Just to name a few of the cases we saw: kids with gashes in their heads, kids with fractured skulls, malnourished kids, casting of fractures, kidney stones (acute abdomen), acute STEMI  (heart attack), and epileptic seizure.  I remember at the end of the last shift in the ER this little boy walked in—maybe 10 or 11 years old.  He turned and stared me down.  Seriously.  I asked if I could help him and he just stared at me…he wasn’t acting in pan or anything.  He walked over to one of the patients getting stitched up and stared at me more from by the patient.  I couldn’t tell if he was with the patient or not because no one spoke to the child.  When the patient got up to leave the little boy followed and then stopped when he got right beside me and stared at me again without saying a word.  The doctors even looked at him and myself.  Finally he left after trying to look at my name tag or my hair (I couldn’t tell).  I am guessing he had never seen a Black person before (I would say foreigner but Aimee was in there beside me and she got no stares) so I am glad I was there.  Not only am I getting exposed to people that I have never seen before but by going on the trip I am exposing people in another country to Black people which they may never see again.

One of our last rotations was Internal Medicine.  We did rounds on the floor with the resident.  He talked with us about labs and asked us thought provoking questions about why we heard certain things in auscultation and what the labs meant.  It was very interesting.  Cases we saw were bronchitis, pneumonia, cachexia, and dengue fever.  Later we were invited to  Dra. Diaz’s home to talk about the difference in pathology, presentation and treatment between Dengue and Malaria (all in Spanish so I had to study up on my Spanish words for certain symptoms).  In our discussion, she said that there had not been a case of Malaria in 3 years and the main tropical illness seen was Dengue.  It was a great educational talk and Dra. Diaz is another amazing woman with a big heart!

What can I say about living in Chone?

Chone, Ecuador

So we went to Chone for our rural experience.  First impressions were…interesting.  There are only dirt roads so we’ve seen a lot of people watering the roads to keep down the dust.  Houses range from open shacks to closed-in concrete large gorgeous buildings.  We have even seen a cow just walking along on the sidewalk.  We’ve seen a couple of Catholic schools and the kids all had on uniforms.  Evidently people don’t see a lot of foreigners here because Aimee and I get stared at quite a bit, many double takes.  And the language is quite different from Quito.  People seem to really run words together and talk from deep in their throat so I’m feeling quite lost sometimes when speaking with people outside the hospital.  It is really hot but I love it…in the shade of course.  Standing in the open sunlight kind of burns the skin so I make sure I have on sunscreen everyday.  We were told to take antimalarial medicine before coming to Chone because of all of the mosquitoes and our beds have an awesome mosquito net draped over it.  Meals at home are good and there have been a few foods we had not experienced in Quito.

Pepe and Marianna, the host family in Chone.

Rice is always served with dinner and we always have a cup of diced pineapple for dessert.  The showers are not really cold but more like room temperature which feels good at the end of a hot day.  Life is very simple here and I am starting to enjoy it.  We have breakfast in the morning, go to the hospital, get about a 1-2 hour lunch break where we go into the center of the town and get some food and use the internet, then back to the hospital for 2-3 more hours, and then taxi home around 5 or 5:30pm.  Dinner is usually at 6:30pm and then we get ready for bed.   I get some time to read, journal, or review my Spanish.  I like the simple life without rushing and deadlines and worries.

Clinic Shifts in Quito, Ecuador

The Atucucho Clinic

Monday we were suppose to go to Atucucho but the doctor did not come to get us at our meeting spot at the school.  We got in a car with a guy that was looking for two students he was suppose to be picking up and then we noticed he was driving in the direction away from Atucucho which is in the hills of Quito.  He ended up calling the doctor that was supposed to pick us up and she told him where to drop us off.  Afterwards, we found out that we were at Toctiuco (spelling?) and we would be there on Friday also.  The doctor there was doing solely obstetrics.  She was not very personable with the patients.  It was like a factory.  The nurse would bring in the folders, the doctor would call in the patient (but mostly the previous patient was given the next patient’s name and told to get them), the doctor would get the HPI, do a quick physical exam, maybe measure the size of the fetus and do a quick dip stick (urine analysis).  She would then prescribe and move on.  We later discovered this was the free clinic and all medications were donated.  I think we saw 14 patients in 3 hours.  It was interesting that the patients had to sign the prescription given and a registry depending on the diagnosis.  We saw one patient get diagnosed with BV by physical exam and no labs.  Sanitation was as best as it could be—all patients sat or laid on the same sheet on the exam table and used the same gown, urine specimens were placed at the same sink the doctor got drinking water from, and gloves were only used for sensitive exams.  By the way, the area we were in is considered dangerous so we have to be escorted and the population it served was very poor.  One lady came in 7 months pregnant and this was her first doctor’s appointment.  We were all shocked to hear this and wondered why it took her so long to come in.  I just wonder what the people there do for jobs and money, etc.

Tuesday and Thursday we went to the Atucucho Clinic.  The doctor there was awesome!  She was very personable with the patients and spent time connecting with them.  Before the shift began, one of the doctors would do a very detailed prayer with the patients as a group.  The doctor we shadowed there does family practice so we saw patients of all ages but no grown men.  The doctor would take her time with emotional patients and offered to pray with them through certain emotional issues.  Between patients she would ask us (the students) if we had any questions or comments.  Although she did not speak much English at all, she made sure she got her point across.  She would also take the time to explain things to patients so they fully understood things.  It is amazing the patient-doctor interaction here.  The patients would open up to the doctor about many personal things an din the end they would also thank the doctor and sometimes thank Aimee and I giving us hugs and kisses on the cheeks.  They are a very grateful people.  I also noticed how friendly the doctors and nurses were at Atucucho. The doctor would walk in the clinic and hug and greet the staff and some of the patients.  Like I said, she was amazing.  The most memorable patient from her shift was an 46 year old female that seemed to be coming in for a check up and her chief complaint was hot flashes.  The doctor did an abbreviated physical exam on her and once she got to starting the pelvic exam and PAP tests the patient broke down and started crying.  In the process of crying, the patient began to tell her story.  She was married with 2 kids.  At one point she got pregnant a third time and her husband forced her to get an abortion because he felt he could not feed a third mouth.  She had to do what he said because she was with his family.    Then she said shortly after the abortion he got another woman pregnant but kept that child.  Having a pelvic exam brought up all of the emotions for her.  The doctor eased the patient into the exam and tried to do what she had to do as quickly and gentle as possible.   The woman had an IUD and when the doctor tired to remove it, th estring broke and she could not get the rst out.  She referred the woman to get an Echo and imaging to have the IUD removed and a host of other labs.  The thing that makes this patient so interesting is how gentle the doctor was with her.  She did not force the pelvic exam and gave the patient time to experience those emotions.  At the end, the doctor spent almost 20 minutes talking with the patient and empowering her to do what she needed to do for her own health and the health of her kids.  She also prayed with the patient.  Aimee and I were in tears.

Wednesday the doctor from the previous day told us we would catch a taxi by ourselves because we would not be shadowing her.  We would still be at Atucucho but with another doctor that was a new resident.  Well the taxi we caught said he knew how to get there before we got into the car and he drove us up the hill but then didn’t know where the clinic was at.  We didn’t have an address to give him because we were not given one and told that we would always be escorted up there by the doctor.  We ended up getting dropped of fat the SubCentral Salud de Atucucho and told him that was wrong.  He then took us to the Salud de Atucucho Lab Corp which was also wrong.  So us Gringos ended up walking back down to the SubCentral Clinic which was a dangerous action on our part.  I didn’t feel safe walking around looking like a foreigner in this not so safe area.  But we got a nurse from that clinic to call back to the Lab Corp and someone came to get us from the lab.  The lab could then call us a cab to take us to the right clinic.  It was the start of a weird day.  Once at the right clinic, we were able to observe the resident.  She did physical exams on kids so they could get their certificates for school.  The nurse would do the vitals and the labs were already done at another agency.  This doctor was really good with the patients and kids.  She explained why they needed labs, the results, and connected well with them.  I was really sick on this day, however, so I had to leave after seeing only three families.  I still wonder how the patients get labs and where—I think it may be a private/government run agency that is standardized and people can go there to get labs done for a fee (maybe they went to the Salud de Atucucho Lab Corp I had been at earlier).

Miscellaneous conversations and observations

Sample of Ecuadorian meal I ate.

At orientation, we met one of the people who would be one of our professors, Luis.  He kind of was like a guide for us.  For lunch one day he insisted we try the Chinese restaurant up from the school.  This was interesting and odd to me but turns out there are many “Chifas” in Quito and all over Ecuador.  Luis said that Ecuadorian Chinese food was different from American Chinese food because it was more authentic because Ecuador and Peru had strong Chinese influences.  The food was so cheap ($3-4) and huge portions were served so that two people could split a dish.  And I must admit, it was good and tasty—not greasy at all!! Later in the week we asked our teacher where we could find “authentic Ecuadorian” food and he said he would take us to a place for lunch in the Central Comerciales (the Mall).  I went to the fast food version of Ecuadorian food and had some kind of pork stomach or belly, a corn that looked like rice (it had been soaked to puff out like that), crispy corn kernels (choclo), and fried banana.  The teachers at the school had Pizza Hut and a burger—funny, they said they wanted a change from the regular food.

I also did have a conversation with “mi abuela” Francia this week.  We talked about my family and I showed her pictures of them.  She asked me about school and once I explained I went to a Naturopathic medical college she got all excited and said that natural/indigenous medicine was important should be bigger here.She said she used it and mentioned the Heel homeopathic remedy company and a homeopathic medicine she takes everyday.  Then she called someone to ask them about the school here but I am not sure if they differentiate between natural medicine and conventional medicine here because natural medicine is not really taught in every medical school.  I want to find out more about that.  Francia, like a true mother, encouraged us to be safe and have fun while in Banos.

In all, I will say that being here is eye opening.  On the way to Banos I noticed how hard people work for just very simple things.  Even though Friday was a Holiday, you still saw people working and building homes and just hustling.  That’s determination and perseverance there.  I definitely love being here, learning the language, and learning the culture.  When I think of coming back, I actually think that returning here is a possibility and I wonder what I’ll be doing—like working at one of the clinics or teaching school or doing something in public health.  Then I think about the conversation I had with a student here who studied abroad in the US.  The student mentioned she felt safer in the US than here.

 

I have talked with some people here just about general life in Ecuador.  Luis gave me a small history lesson.  He mentioned how racism existed here because during colonization, the Europeans procreated with the indigenous people and this group seems to view themselves as better and more privileged than the indigenous people.  The native people seem to be very poor and have fewer resources available to them.

CFHI Clinical Orientation

The first week I would do only Spanish classes in the morning and evening and then the second week I would go to clinic shift in the morning and have Spanish classes in the evening.  Because our program was Urban Rural Health Comparative, my classmate and I were assigned a community clinic shift that deals with a rural population of Quito which was going to be in the hills of Ecuador known as a “rough area”  A doctor will be escorting us up there when we start our shift next week.  Then the third week we would travel to Chone and stay there until the end of the fourth week.  So I guess we are suppose to compare this clinic to the rural area of Chone (where we will have no Spanish classes).  The orientation doctors then took us to tour the Maternity Hospital and the Military Hospital (or at least to find them since some students would be doing their rotations there).  We got a chance to start using public transportation during this time.  Public transportation is really cheap here.  We took a trolly for $0.25 and someone said it could be used for an all day pass but I am not sure about that.  The Maternity Hospital seemed low on resources and we were told births mostly occurred on tables.  There was a hospital beside it that wasn’t as good either.  As a matter of fact, they were closed when we went by it.  Someone mentioned they were closed (in advance) for the Holiday of course.  Beside that was the very clean Military Hospital that is semi-private so military could get treated for free but the public could get treated also for a small price.  Seeing these places made me want to do rotations there also so I must come back!!

We also had a presentation by Dra. Susana Alvear, the medical director followed by a discussion.  She talked about the Ecuador health care system.  As of 2006, 38.3% of the population is below the international poverty line.  In the urban areas, 80% have clean water and 61% have sanitation.  In the rural areas, 37% have clean water and 33% have sanitation.  Because of this, I would expect to see more waterborne illnesses in the rural areas.  The infant mortality rate under 1 year of age was 22/1,000 live births in 2008.  This high rate is thought to be due to the need of more resources and nutritional food(there was 18% malnutrition overall with 27% malnutrition in the rural areas).  With this high infant mortality rate, I also think about prenatal care and access to that care.  Dra. Alvear mentioned that Ecuador has a national health care system (National Health Council) that has both public sub-sectors (in which anyone can go to and not pay anything) and private sub-sectors (which is like an HMO).  There is a lot of bureaucracy in the public sub-sector.  The total population covered by public, private, social security, and military is 79%.  Rural areas use traditional medicine which I would love to get more information about.  There is also ~30% of the population that is not covered.  They just changed the law mandating doctors work 8 hours/day instead of 4 hours/day in the public sub-sector I believe.  This might decrease the quality of care because visits will be 10 minutes instead of 20 minutes.  This makes me think of how naturopathic medicine differs from “conventional” medicine in the US.  The shortest visit I have seen with Naturopathic Physicians is 30-45 min.  Dra. Alvear also talked of how there is an increase in chronic disease and diabetes in Ecuador.  It was very interesting that African Ecuadorians have increased risk and incidence of hypertension the same as African Americans.  The difference is African Ecuadorians do not get first line treatment for hypertension which is known to assist in lowering blood pressure in African Americans.  Later, I also spoke with Dra. Alvear about missionary work in Africa that she also does.  She also seems really interested in naturopathic medicine.  She is an awesome lady with a big heart!!

First Day in Ecuador–General Orientation

I wanted to write about my flight experience last night but I was way too tired.  We (my classmate Aimee is doing the program with me) basically flew all day—from 6am till 11:20pm.  My host family is an 80 year old female named Francia Ducos.  She knows some English (I think she helped establish the Spanish School here) but speaks mostly (all) Spanish to me.  I only feel somewhat lost and she is very patient with me in explaining things.  There is one other student staying in the house with me—she is Denise from San Francisco.  We each have our own rooms but we share a tiny bathroom.  The house is very lovely and simple.  There are 4 locks on the barred door and one on the wood door.  People here seem to lock up everything.  We even have locks to our rooms that Francia locks when she leaves the house while we are gone to school and clinic.  They say crime is very bad here.  They emphasize taking precautions like wearing a book bag on your front which I actually saw many locals doing.  Last night I was so tired and Francia insisted I go to bed immediately because she knew we would have a long day today with orientation. I slept ok… actually I slept pretty well considering hearing sirens all times in the night (we live near the police station I believe) and waking up to use the bathroom for a second time.  I actually felt very secure.

Rachelle, Francia, and Denise

Before I went to bed, Francia gave me a hug and was smiling. This morning at breakfast, she said Denise and I were her daughters this month.  Denise actually came a week early to start early with Spanish classes and she does very well conversing with Francia.  So I think taking the week of Spanish classes is going to be very beneficial on my part.  Francia made us breakfast which was a bowl of mixed fruit (apples and bananas) and toast with a slice of strong cheese.  My appetite seems very low either from nervousness or the high altitude so I did not eat much.  Denise and I walked to the Amazing Andes Spanish School together and met the other students.  Most are still in their undergraduate years but 3 of us are in Medical School.  As for free time, the local coordinator (Rosita) at the Spanish School actually had some activities planned for the group of students to do.  It turns out August 10^this Ecuador Independence Day and therefore Friday is a Holiday.  Rosita said it would be the perfect time to go to Banos for the weekend because we could do many activities there.  We could stay in a “hostel” and go see the waterfalls, go horseback riding and a lot of other stuff.  The whole class decided it was a great idea.   After weekend events were decided, we then took another Spanish test too assess our level of Spanish knowledge (reading and writing).  I am glad I took a refresher class of Conversational Spanish but I wish I would have reviewed more.

About me and CFHI

Hi!  I am Rachelle Johnson, a 4^th year medical student at National College of Natural Medicine.  I am currently working on a Doctorate in Naturopathic Medicine and a Masters of Science in Oriental Medicine.  Because I am doing two programs, Summer 2011 is going to be my last “free” summer where I would not have to attend classes nor do clinic shifts for school, so I wanted to travel abroad and get preceptorship (mandatory shadowing) hours while learning about another culture and working on medical Spanish.  I chose to do the Urban Rural Health Comparative program in Ecuador because I also have a Masters in Public Health and wanted to do a program that allowed me to observe the public health care system in another country.  As a Naturopathic Physician, I would like to work with minority groups and chronic diseases prominent in minority groups.  I also would like to work with in other underserved areas and with immigrants.  These groups tend to have more health issues and less access to care compared to other members of society.  Such illnesses are high blood pressure, heart disease, diabetes, cancer, asthma, and HIV/AIDS.  I am thankful to have received a Minority Scholarship to attend because I think it is important explore the world to get a better global view of health.  Money should not be a factor in participating in amazing opportunities such as this.  I wanted to keep a record of this experience and journey at this time in my life so in this blog I have included a lot of entries from my journal that I kept while in Ecuador.  I hope that this shines a little light on my experience and it encourages you to find your own experiences similar to this.  Enjoy.