Re-entry questions stolen from El Nomad

Sitting in Quito's airport food court, I can continue to reflect on my time in Cuenca. Steph's flight is delayed, so I still have 3 more hours of sitting to do (already been here 4.5).

I'm going to take my lead from the re-entry questions that El Nomad had me complete before I left. I think they were a really good way to get me thinking about my time in Cuenca.

The effect on my work/career plans:
Well, I still want to be in medical school, so that's definitely a good thing. Spending time in a 9-to-5 general clinic did make me realize that clinic life might be too slow for me. There's a lot of sitting and waiting and appointments when nothing seems to get done. I won't say that I am eliminating clinic based specialties, just that I want to spend some more time investigating the other possibilities out there.
I did enjoy experiencing a public health system, because that gave me a different outlook on the system that we have in the United States. The whole process and plan of care is radically different, because it is based on the resources provided by the government plus whatever the patient might be able to afford. It has its pros and cons, just like the private system, but I think that US physicians and medical students could learn a lot from some time working or shadowing in a public system.
Finally, one of the main reasons I wanted to go abroad this summer, I improved my medical spanish. I learned a lot of new terms and got more comfortable listening to patients explain their problems and concerns.

The effect on my hobbies/interests:
I still love to travel, and spending time in Cuenca reaffirmed that. When I came back from my semester in Spain, I told myself I would do a better job of exploring my own country, since that was a more affordable option. I did see a lot of the west coast last summer, but there is still a lot to explore. Hopefully my traveling spirit will remain and I can experience more of the United States when I return from this adventure.
Another one of my goals on this trip was to expand my culinary repertoire. i have already learned how to cook some basic Ecuadorian dishes, and my host mom Clarita is sending me more recipes so that I can keep cooking when I get home. I'm very excited to make empanadas and morocho for all my friends.

The most proud moment during my time in Cuenca:
When my host mom Clarita called me "mi hijita" (my 'little' daughter) for the first time. I never thought that I would be welcomed into their home as a daughter, and I was so proud that she thought me worth of this term of endearment. She used it and many others throughout my time there, and my little host brother Juan Diego even called me "mi gringa" (my white person, not derogatory in Ecuador) a couple of times. I really appreciated their kind and welcoming demeanor, and it meant a lot to me.

The most humbling moment during my time in Cuenca:
The first day of my internship, going home on the bus. Ariana and I could not get off the bus. Every time we tried to stand up and press the button, we would fail and fall back down in a fit of laughter. But the laughter was mostly to keep the tears back. I really thought we were never going to get off the bus. I finally had to ask the young man sitting in front of us how to get off, and after explaining that you get off at the blue stop, I had to reiterate that it was the physical "bajando" that we did not understand. When we finally did escape, I laughed so hard my side hurt. It was a definitely reminder that while I am a pretty smart traveler that knows how to get around new cities, I still had a lot to learn.

Finally, to steal from my friend Colin's travel accounts, here is the list of books I read while in Cuenca. And for fun, the movies I watched too.
Books:
The Other Queen by Philippa Gregory
The Scarlet Letter by Nathaniel Hawthorne
All I Really Need To Know I Learned In Kindergarten by Robert Fulghum
Candide by Voltaire
The Giver by Lois Lowry
Hospital Sketches by Louisa May Alcott

Movies:
Wolf of Wall Street
The Butler
The Bling Ring
Up in the Air
Frozen (with Spanish dubbing)

Leaving Cuenca

Wow, I don't even know how to start this post. I'm sitting here on 6-year-old Juan Diego's bed, all of my belongings packed around me (save this iPad), entirely unsure how to feel. I can't wait to see my sister Steph and start our traveling adventures together, but leaving just seems strange.

My leaving started at 6:40 am local time, when I woke up to say goodbye to Juan Diego before he went to school. Last night, I told him that no matter what he could not go to school without saying goodbye to me. That if I was still asleep, he was to knock on my (his) door and get me up. Of course, since I'm traveling today, I was awake 5 minutes before my alarm, and had already started my laundry before he came out of his parents' room. Then I heard him tell him parents exactly what I had said to him the night before, and he calculated exactly how many minutes everything would take him so he would only be 2 minutes late for the buseta. I couldv'e cried right there. But he came out of the other room, hair slicked back, in his school uniform, and gave me a polite hug around the waist. We both said "ciao" and I responded with "que te vaya bien" and he with "a ti igual" and then ran out the door. It was the simplest and sweetest goodbye, as if he would see me in a few hours.

Daniel, my 15 year old host brother, came into my room a few hours later while I was packing, backpack in hand, to say goodbye. He is a quiet teenager, particularly around me, but very polite. We said our goodbyes in a similar way as mine with Juan Diego, but I hugged him just a little tighter. I still consider him my Ecuadorian brother, and wanted him to know that I would miss him just as much, without getting sappy in a way that I know teenagers despise. And off he went.

Now all that's left is to say goodbye to my host parents, Juan and Clarita. Currently they are sitting in other rooms of the apartment, doing other things, since I don't have to leave their house for another hour. I'm not how sure to express in English or Spanish how much I have appreciated their kindness and love. Just this morning when I was sitting at the kitchen table eating breakfast, and my host mom came into the kitchen with a bag of Ecuadorian coffee to use with my chuspa (an ecuadorian coffee making contraption) when I get home, as well as a beautiful artisenal ceramic to hang up on my wall. I was so touched, especially since I meant to bring her flowers and didn't have the time. And yesterday Juan told me I had to come back so I can help him with his pronunciation of English songs (he sings and plays the guitar). There is no end to the wonderful things I could say about them. Leaving them is going to be near impossible.

I'll most likely post again from the airport later with less emotional and sappy thoughts, but this will have to do for now.

An unplanned change: to Tandacatu!

I didn't expect this to happen, especially not after three weeks working at el subcentro de salud San Pedro. But this weekend, Ariana (the other student from El Nomad) and I were asked not return. Not because of anything we did or did not do, just because there were too many international students at the subcenter and they didn't think it was fair to the other students not to give them a chance to see how the subcenter works. So on Satuday, we stood dumbfounded and unsure of what would become of our last week.

Luckily, El Nomad is run by some awesome people, and they were able to get us a new placement that we started today (Tuesday). So we arrived at el subcentro de salud Tandacatu to meet the new medical staff we would be spending 4 days (from 8 am to 1 pm) with. Even though it means starting all over, it is definitely interesting to see how another subcenter works. Here are just a few of the differences that I noticed today:

San Pedro serves almost 12,000 patients; Tandacatu serves a little over 4,100.
San Pedro employs 2 doctors, 2 dentists, and 2 nurses; Tandacatu has 1 doctor, 1 dentist, and 2 nurses.
San Pedro was full of students (5 ecuadorian and countless international); the only students at Tandacatu are me and Ariana.
The patients of San Pedro are spread out all over a semi-rural area; Tandacatu is in the city, between my neighborhood and el Centro, and the patients live very close.
Tandacatu is smaller, more organized, and run much more efficiently.
Tandacatu is staffed entirely by women, which lends it a totally different atmosphere.

And this was just today. And these are only some of the differences. And this doesn't include the similarities. Here are a few:

Both places are often out of important medicine that their patients need.
Both places run similar if not identical community outreach programs.
Both places take stern attitudes with patients who do not follow "doctor's orders".

This week will certainly be a different experience in compared with the last three. It is difficult to get comfortable with and understand the routines of a place in 4 days, much less get to know the staff at all. But I think it will be for the best, not matter what happens, because I came to Ecuador to experience the health system and what better way to do that then see both the more rural and urban patient populations and clinical settings. So here's to new and unexpected experiences!

Living Mundial

It seems only appropriate that I write about Mundial (the World Cup) since Ecuador beat Honduras yesterday 2-1. Living in a country that cares so much about futbol and Mundial has made me a futbol/soccer watcher, if not an aficionado. I still don't understand the majority of the rules, nor the point system of the tournament, but "GGGGGOOOOOOLLLLLLLLLLLLLLLLL" is something I understand and consider part of the universal language of sports. Any bar you walk into will have the game on, no matter who is playing. Even the television in the waiting room of the subcenter where I am working has Mundial on all day. We closed one hour early yesterday (Friday) just so everyone could have time to get home for the game at 5 pm. And a large number of extended family members came over yesterday to watch, stress, and then celebrate together. One of my friends that I met here told me that apparently the USA game was on a huge screen in Times Square and when a goal was scored, not even one person flinched or took notice. I am definitely the same as all of those people in the United States, but being here it feels different. Futbol feels important. It is part of the culture, part of the family, part of the living spirit of Ecuador. And I have to say, I love it. VIVE ECUADOR!!

Fuimos a la playa!! Ayampe, Ecuador

This past weekend, I went to Ayampe, Ecuador with other members of my program, El Nomad, as well as Arturo, Pip, and Flo, who run/work for El Nomad. Ayampe is a beach town that most Ecuadorians haven't even heard of because it is so small. Most people I told just looked at me like I was crazy.

I could understand why once I arrived. Ayampe is made up of 4 or 5 hotels, and about that many restaurants, all surrounded by houses and tiendas (shops). It is on the beach between the well-known tourist-filled Montanita and Puerto Lopez, where you go to get to Isla de la Plata (more on that later). It is about 5 hours drive from Cuenca.

The whole weekend was awesome, especially since we didn't have access to the internet and barely had cell service. So it was definitely an escape and a great way to spend the weekend. I'll just hit on some of the higlights.

Isla de la Plata::
AKA the Poor Man's Galapagos, since it has some of the same species but is only an hour boat ride off the coast from Puerto Lopez.
On the way there, we got to see two whales (ballenas)!
I also got to see piqueros de pata azul, fragatas, and many other species on the island.
It's name comes either from a hidden treasure or the silver appearance of the rocks covered in bird s***.
We went on a 2 hour hike, and then went snorkeling!!! It was my first time and it was awesome.

Los Frailes::
Just one of the beaches that we visited on Sunday.
Each one is a little different but they are all connected either directly or by paths.
There was a lot of biodiversity here as well, including sea urchins (erizo del mar), one of which I fell on and got spines stuck in my foot. I'm okay though, no worries.

Both of these locations are part of the larger Parque Nacional Machalilla.

It was nice to be away from the altitude and in a hot climate. Though it was humid and filled with mosquitos. We had a little rain at the beach on Sunday, but otherwise pretty good weather. I tried ecuadorian ceviche (different than others apparently) at Mariscal's restaurant, as well as lots of other delicious foods. I spent my down time reading or hanging out with the others in hammocks in a tiki-style gazebo.

The easiest way to summarize my weekend is by the numbers:
92 photos
23 mosquito bites
5 holes in my left foot from sea urchin spines
2 burnt ears
1 scraped knee
1 book finished
So, all-in-all, an awesome weekend!

Methods of sterilization and cleanliness

I don't know whether it will surprise you or not to know that the standards of hygiene and sterile precautions here in Cuenca are much different than in the United States. I think it is due to many different factors, such as the lack of resources, a government run system, and I believe it is both caused by and causes the people here to have much better immune systems. Obviously they get sick just like Americans, but the lack of constant hand sanitizer use has not exactly impacted them detrimentally that I can see.

Here are a few examples:
The only time the doctor puts on surgical level gloves is to deal with an open wound.
The only other times the doctor puts on gloves at all are to perform Pap smears and other vaginal examinations, to check the genital area of growing boys, and to check on a wound that is healing.
Washing of hands usually occurs only once gloves have been removed.
The other doctor does use hand sanitizer occasionally but not nearly to the extent that it is used in the US; it is more to replace occasional hand washing.
All patients sit on the same bed, with no paper covering or changing of sheets (because there are none).
All patients who have to wear a gown put on the same gown that lives in the bathroom connected to the office.
Many items in the office are wrapped in brown paper to keep them sterile, however these items are wrapped by nursing and medical students (like myself) without any extra precautions.

There are also still standard precautions for equipment that needs to be sterile of course. Instruments for Pap smears and other vaginal examinations come in sealed plastic containers. Sutures and syringes are in the same peel open container seen in the US. Wound cleaning and suture kits are sterilized and stored properly. I don't want to misconstrue the system and make anyone thing that sterilization is just willy-nilly. They have a very good program and process in place.

I don't see too much wrong with the system that they use. Mostly because it makes sense with the resources they have access too. Also, with all of the hype about the "hygiene hypothesis" it is interesting to experience a medical system that, if this hypothesis is true, is not perpetuating it. The biggest problem I have found with this system is that if the doctor wants surgical level gloves, sutures, or a syringe, she has to write a prescription and send the patient to the pharmacy (in the same building) to get it. These things are not on hand. Even though I know this is their protocol and a method to maintain inventory, it seems like an unnecessary impediment to efficient medical care. However, overall I have enjoyed experiencing a completely different approach to hygiene and medical cleanliness.

Mensajeros de la Paz (Messengers of Peace)

Today in the afternoon we went to visit some of the descapacitados (disabled persons) who live in the San Pedro de Cebollar region. It was on the schedule, so I knew it was happening today. And I was a little anxious. I had no idea if this meant home visits, a school, or some kind of institution. What we actually saw surprised me.

Mensajeros de la Paz is a center for disabled persons, either intellectually or physically (or both), most of whom have been abandoned or neglected by their family. This is not a requirement nor a given fact, but most are in this location because their family could not or would not care for them. Currently the center has 8 girls and 12 boys. It is composed of multiple buildings with ample facilities for therapy and for the normal daily life of its rambunctious occupants. I don't think I have ever seen a home like this one before. Much bigger than any orphanage you can imagine, and seemingly much better equipped and prepared than most institutions and centers for the disabled in the United States. I was honestly shocked when we arrived because I expected something more like a hospital ward.

Today, we gave the boys check-ups, just like we have been doing at the schools, without the vision checks. They all live in a Spanish-style house, complete with kitchen, dining room, tv room, and an enclosed center region that is normally exposed to the elements. They do share rooms, but it seems that they spend most of their time out in the common areas. I don't think I would be stretching it much to say it's like a fraternity house in many ways, particularly in the atmosphere and comraderie between its occupants.

It's difficult for me to articulate how today made me feel. I was so nervous and apprehensive at the start, and I left laughing with a huge smile on my face. Even though la doctora explained that they have had problems with neglect and poor care, I could not help but feel glad for these lost souls, that they had a place to live and call mostly their own. There are many more things that have run through my mind and my heart, but they aren't exactly writable or expressable. So I will have to leave it at that.

Learning to cook empanadas!

Today for our cultural activity we learned how to make empanadas with Arturo's mom. All set up by Pip and Flo (a required shout-out). So here is the recipe that I will be attempting to recreate when I get home! Hopefully I can get some of Pip's pictures and post them later.

Ingredients:
4 cups of flour, sifted
1½ cups of water
2 tablespoons of margarine/butter/manteca (pig's fat)
Salt
Sugar
Filling mixture*

Steps:
1. Heat water, margine/butter/manteca, ~½ tablespoon of salt, and ~½ tablespoon of sugar until boiling, remove from heat.
2. Combine flour and water. Mix and add additional water or flour until consistency is so that the mixture does not stick to the bowl or your hands.
3. Leave out for at least 2 hours (recommended but not required).
4. Stretch out, hard to explain but not kneading.
5. Make all of the dough into small balls.
6. Start with the first ball you made and roll it out thin.
7. Add filling mixture*, fold in half, and smush closed.
8. Pick up, close again, and make orejas (ears) with the edge. Again hard to explain.
9. Place aside, all separate.
Option 1 - frying
  A. Heat a few inches of oil in a small pot.
  B. Test the heat of the oil by dipping the end of an empanada in.
  C. When it is hot, fry, flip, and repeat until they are done/dark.
  D. Lift out, drain, place in bowl with napkins, sprinkle sugar, let cool.
Option 2 - baking (better for meat filled)
  A. Use less fat when making dough.
  B. Add egg wash before baking.
  I don't actually know the rest of the details of this method, I have to ask.

*Filling options*:
Queso (cheese)
Queso + marmelada (marmalade)
Banano
Queso + aceitunas (olives)
Queso + arroz (rice) + cebolla (onion)
Y más!!

Better than Baltimore? Maybe not

After just a few days here in Cuenca, I found myself noting all the ways that it is a much better city than Baltimore. For one, the full name is Santa Ana de los cuatro rios de Cuenca, and it lives up to its name. Cuenca is a very green city, filled with trees, parks/plazas, and four rivers surrounded by green banks and running paths. It is also filled with outdoor markets where you can by anything from fried plantain to hand-made jewelry to leggings. There seems to be no end to the exciting surprises waiting around every corner. All I could think about upon my arrival was how great it was to be out of Baltimore and how beautiful and amazing Cuenca must be.

However, I have now begin to see all the ways that Cuenca is not so different from Baltimore. It really hit me when la doctora I work with told me that I had to take a cab to the bus stop, because it wasn't a safe place to be after/at 8 pm. These two radically different and unique cities actually have some things, good and bad, in common:
1) Safety is an issue - there are places you cannot go at night, others you cannot visit during the day, and others where being a tourist makes you vulnerable.
2) The bus system has is pros...and cons - here in Cuenca, they are decently reliable and very cheap ($0.25 a ride), but you have no idea which buses go where until you ride them or find someone who can tell you. In Baltimore, you can look up all of the timestables, stops, and routes, but no guarantee the bus is going to follow them. And don't forget the congestion/pollution from both systems.
3) It is the less traveled, less appreciated of local cities - Both are often overshadowed by their larger or more appealing neighbors. Examples include Quito, Guayaquil, and Washington DC.
And I am sure that there are many more similarities between my two current lodgings that I have yet to discover.

El subcentro de salud San Pedro

First, a little background on Ecuador's healthcare system:
It is actually a combination of public, Social Security, and private. The public system is a four-tiered system, starting in the community and working towards Quito, the capital and largest city.
1) Subcentros de salud (SCS) - local community based clinics that deal with everyday problems and act as a triage for anyone needing to see a specialist or get further testing. But oh are they so much more.
2) Hospital - where patients go for any testing, to see any specialists, or for any emergencies that cannot be handled in the SCS.
3) Specialty hospital - Children's, oncologic, etc. Any specialty that might require its own space.
4) Regional hospitals - located in Quito and Guayaquil.
This structure has changed in many different ways over the years, and I haven't had exposure to anything except level 1, el subcentro. Anyone who knows more than me, I apologize if I write anything in error. I'm just reporting my knowledge and experiences.

Un subcentro de salud (subcenter of health) is rural/family/general medicine at its finest, at least in my opinion. Every patient in the respective region is known and accounted for. The doctors care about their patients but are also stern with them when they need to be serious about their health. They use the resources they have and are much more capable than many other doctors who might rely on tests and imaging too often. However, they known when tests and imaging are necessary and are more than happy to send a patient to the hospital when it is warranted. Vaccinations, prescriptions, and nutritional support are all found and administered on site. If a patient hasn't been showing up to their appointments, the doctors take time out of their clinic hours to show up at the patient's door and ask what is going on. The best part about all of this, it's FREE.

There is obviously a lot more going on behind the scenes, but the doctors are committed to their patients and providing them the best care possible. The other parts of their jobs are just par for the course. And they aren't really those that you see in the United States. Some of these responsibilities include:
 -- Holding monthly "clubs" for patients with hypertension, diabetes, and those who are pregnant in order to perform check-ups, give nutritional and lifestyle advice, and get everyone together to deal with any issues (like a rude EKG tech and incompetent cardiologist at the local hospital).
 -- Going to all the schools in the region to perform check-ups on all the students including height, weight, age, vision, and general well-being.
 -- Keeping tabs on all pregnant patients, particularly those at some sort of risk.
 -- Completing monthly statistical reports, detailing the health of the patients in the region and what services were performed at the SCS.
 -- Performing home visits for any patients that cannot make it to the SCS, whether they be elderly, pregnant, or disabled.
All of this on top of clinic hours at a place that is open Monday through Saturday, 8 am to 5 pm (with a 1 hour lunch break). Did I mention that there are only 2 doctors?

The doctors at SCS San Pedro are lucky that right now they have a Family Medicine resident as well as a medical student in her final year of study helping them. They both truly appreciate this assistance because they have a lot on their plate. The other staff of the center include una licenciadora (meaning she has achieved a Master's), 3 nursing interns, and the constant ebb and flow of foreign students passing through to learn and assist however possible.

I fit into this final category. I am at the SCS in a shadowing/volunteering/educational capacity. However, my role is very flexible. As my program told me, I will get out what I put in. So far, I have already learned a lot and although I know that right now I may not be very helpful, I know that as I get my bearings and get used to how the clinic runs, I will become a more useful part of this well oiled machine.

Some of the amazing and striking things I have seen so far include:
A 42 year old 1st time mom holding her 10 month old son, both she and the husband/father so overjoyed that he is progressing well.
The same day, an 18 year old going into labor and being sent to the hospital, and hearing her mother respond "soltera" (single) when asked about her marital status.
Patients coming in to request birth control implants so that their husbands don't know they are on birth control.
Discovering a likely pulmonic heart murmor on the day I listened to at least 30 hearts.
Osteomyelitis still persisting 1 year after hip surgery, being treated in the home.

I am going to post shorter thoughts throughout the week, but won't be posting them to Facebook just because I don't need to spam all of my friends' News Feeds. So if you like what you read, come back and check things out more often.

Living with an Ecuadorian family

Well, I've been here for about 4 days, so it seemed like a good time to write about my host family here in Cuenca. I had limited information when I arrived, just that my family had two sons and a mother named Clarita. I had an address but puting it into Google Maps didn't really tell me much since I knew nothing about Cuenca before arriving. So I packed the gifts I bought blindly (DC mug, Old Bay, and Orioles hats) and hoped everything would work out

I was nervous that the whole family wouldn't like their gifts but they all got so excited and we even took a picture with the boys in their Orioles baseball caps. I'm so glad that they are so kind and welcoming. Even though I am still nervous and awkward, I know that we will figure it out and things will be very normal soon.

Like many other Latin American cultures, the family is very improtant here in Ecuador. My family consists mainly of an immediate family who live in this apartment: Juan, Clarita, Daniel, y Juan Diego. But it also includes la abuela (the grandmother) who lives in the apartment next door, and many tías (aunts) and other family members I have not yet met. The front door to the apartment stays open most of the time so that we can come and go between here and la abuela's apartment. This is particularly important now since I am living in Juan Diego's room and he is staying over at la abuela's. I haven't quite figured out the family roles yet, but I think I will in time.

This is my first long-term experience with a host family, and in a foreign country no less. I spent overnights in the US with many families, but there was no language barrier and if we did not "click" it did not matter since I left the next day anyways. This situation is more delicate since I will be here a month and I want to make sure I don't offend anyone. I have to remember to both be myself and be respectful. I know they have already welcomed me in and consider me part of the family. My host mom calls me "mi hija" (my daughter) and Juan Diego, who is 6, hugs me all the time and constantly wants to play. I think la abuela is warming up to me, but she wasn't too pleased when I bought Juan Diego some chocolates. It wasn't the chocolates that seemed to concern her, but more that I paid for them with my own money. It seems there may be a bit of pride when it comes to money, in general not just in my family, but I will have to see if this is true or just a few experiences.

Today, I ate two lunches, to give you an idea about the way that Ecuadorian moms can be. I ate lunch at 12 pm with the doctor I am working with at a small cafe near the subcenter of health. My host mom called me at 1:30 to see if I was coming home for lunch, and when I said no she told me she would save it for later. So when I got home, she asked if I was hungry. I said a little, so maybe I would just eat some of the food she saved. I was presented with a full lunch: fish, rice, salad, a pear, and a smoothie. And I ate almost all of it, because it is delicious and you never want to insult your host mother's food. Also, I'm pretty sure she used the Old Bay I brought her on the fish. So how could I not eat it?

This is a bit jumbled, but I'm sure I'll add more things later. Adios for now.