there's no place like... ecuador.

I'm sitting in the airport now, waiting to board for my long way home. This past week has been a whirlwind. On Saturday morning, I finished up my last night of call, packed up my things, and said my goodbyes. On my way to the bus stop, a little 5 year old ran out of his mother's shop to yell "Hola Doctorita"... I had treated him for an ear infection at 2am... but his little greeting somehow softened my lack of sleep on his account.

Monday, my dear friend Sarah and I headed out for a great adventure... climbing the world's 2nd highest active volcano, Volcan Cotopaxi, sitting in splendor at 5897meters (19348feet). We hiked up to the refuge to leave our stuff, and headed up the glacier a bit for "Glacier School," the how to crash course on ice axes, crampons (like giant metal 12 point claws that strap on the bottom of the boots), and how to fall down the glacier gracefully.

We slept (or tried) for a few hours on 1.5 ft wide bunk beds stacked three high in the refuge. The guy next to me was snoring loud enough that I was grateful for the sound of the alarm at 12:30am. We got on all our gear and had some breakfast and headed out into pitch black, lit only by our headlamps, by the almost full moon, and a host of brilliant stars... between the waves of fog, wind and snow. Let's just say, I'm glad it was REALLY dark, because I couldn't see the glacier drop off for thousands of feet.
Sarah is an all star mountain climber (being from the Alps, she's a natural), and pushed our pace the whole time. We snacked on chocolate bars and gatorade throughout the night and steadily climbed in elevation. Parts were SO steep and windy, parts we had to take BIG steps over crevasses in the ice, but for the most part, I couldn't help but marvel at the grandness of it all.

The last 80 meters of elevation were the toughest. The sun had just begun to come up, it was incredibly steep, incredibly windy, and just negative 25 degrees celcius. We came over one ridge (that I thought was the top) only to have another higher ridge ahead.... but when we reached the summit, I realized once again why I love the mountains.

The sun was pouring in, the cold wind sweeping snow across the rim of the volcanic crater, several other summits (Chimborazo, the Illinizas, Cayambe) were visible above the cloud line as well. It was breathtaking. I couldn't help but praise the amazing Artist that created it all.
It took only an hour and a half to descend what had taken almost 5 hours to climb!

To see the sharp contrast of the jungle, the glacier topped volcanoes, the big city of Quito... it's pretty incredible that such a tiny country has so much variety of culture and geography. But I'm convinced once again, that what makes a place is its people... and I will miss my dear friends in Ecuador.

ciao pescado...

This afternoon I was walking home from the bus stop and a man yelled out to me from his front porch..."I'm Claude, remember me?"  He took his hat off so I could see his face better, "I was really sick, you saw me in the emergency room.  I'm all better now."  Honestly, I don't really remember him.  I vaguely remember a man named Claude, and remember thinking it wasn't a very Ecuadorian sounding name... but it was still an honor that Claude remembered me.  Probably because I'm one of the only Gringas he's ever met. 

A man came into the ER the other night.  He had gone to his girlfriend's house to ask her parents for her hand in marriage.  When he asked, the mother in law got really upset that he was taking her little girl away from her (and she had been drinking quite a bit)... she pulled out a machete and chopped his forearm.  He was asking for her hand, but he almost lost his!

I'm on call tomorrow until Saturday, then I'll leave Shell Saturday afternoon to head up north to travel for a few days...  

Sangay, El Altar, y "Coche 22"

This morning is the clearest morning I've seen yet during my time here.  From my window I can see 2 volcanoes bursting up from the horizon.  Really, they look a little out of place  The grass and trees are so green and the mountains I can usually see are lush with vegetation... but these volcanoes aren't shy... they are snow capped, brilliant, and put the rest of the mountains to shame for beauty and size.

Volcan Sangay (above) and El Altar (below).

I am nearing the end of my second to last "turno"  (aka. on-call day) here at HVO.  I had a patient come in last evening unresponsive, basically all of his organs have shut down except his heart and lungs.  I was sitting in the room with him writing on his chart when I realized I hadn't heard his gurgly breathing in a few seconds.  I quickly listened for breath sounds, ran to the hallway to elicit some help, and we called a "Coche 22".  I'm still confused as to why a "Code" (aka. code blue, harvey team, when someone's goes into cardio/pulmonary arrest) is called a coche 22... it translates to something like "22nd cart".  I intubated him and used the ambu-bag for a good 1.5 hours while the ventilator was being set up.  He's still hanging in there this morning, and thankfully his whole family has been able to come to be with him in his last hours.  They are from a very rural jungle area...His son showed up last night with indian paint masking his face.

the basilica in quito.

el tiempo esta volando

Well, it's hard to believe that I have just 1 more week left of work at Hospital Vozandes.  The first few days I was here, I thought 2 months would last forever... now I'm wishing for a few more months.  When I finish call on Saturday, I'll head back North to climb Cotopaxi (the highest active volcano in the world!), and spend a few days in the mountains before coming home to Memphis on the 22nd. 

I just got home from Quito tonight after a weekend off to experience a little more of Ecuador.  Pictures and stories to come...  I'm tired.

the problem with short term medical missions

So, I realize that I'm walking a fine line with this post, but I have to get it out there... it's just something that's been stewing in my head ever since I met little Paulo.  He's the kiddo I mentioned a few posts ago who we operated on for Congenital Pseudoarthosis.  

Paulo was born with this rare bone disorder that causes one of leg to be bowed so badly that it spontaneously fractures.  After the fracture, the circulation becomes compromised and the leg is not able to heal properly.  This leaves a mangled, deformed limb with a sort of "false" joint.  

Paulo came to Hospital Vozandes to visit his sweet grandmother who has been coming in for wound care every day for the past few weeks.  He hobbled.  I can't think of a better word for it.  It wasn't a limp, it was more like he jumped from his right foot with his left foot only barely skimming the floor.  

Paulo had surgery 3 years ago to correct his leg fracture.  So, you ask, why was he still limping?  Lack of follow up care.  A team of docs who didn't know his case well enough.  A surgeon with a "save the world in one week" mentality.  Yeah, I know, this is where I'm starting to walk a fine line.

Cuban surgeons visited his little mountain town 3 years ago, saw his leg, took an x-ray, put an intramedullary pin through the bone, and went back to Cuba.  

They didn't know, or didn't take the time to understand, that his was not a simple broken leg.  Because of the compromised circulation that comes along with the disorder he has, his bone never healed.  And they weren't around to know about the results of their surgery--which is what we had to deal with... a left leg 3 centimeters shorter than the right with a deformed "knob" of bone above the ankle.

We took out about 3 more centimeters of bone, and externally fixated it, so hopefully that segment will heal.  In the next few years, Dr. Wolff will go back in to lengthen the bone below the knee.  It may or may not work, but it's the only chance he has... otherwise they'll have to amputate below the knee.

Now don't get me wrong, I do think there's a time and place for short term international medical work.  For example, taking over for a long term doc who needs a few weeks of vacation, going into an established hospital to teach a new surgical technique or donate a new piece of equipment and show them how it works, even going to work somewhere for a few days when you work with a local doctor who can give follow up care.  But we all agreed when we got into this doctoring thing that we would "do no harm"... and sometimes fixing something, whether surgically or with a prescription, without being there to see how it results can be doing a lot more harm than if it hadn't been fixed at all.  Just something I've been pondering... what do you think?

to the hilt

Let me give you a little insight on life in international missionary medicine:  I have a very difficult time picking which amazing, crazy, breathtaking, heart wrenching, frightening, or comical event to post... there is much too much going on, too much I'm learning and seeing and experiencing to be able to summarize in a few pictures and a few paragraphs.  Please know that my experience here, my life this past 6 weeks, has been far more exciting than this blog gives it credit.

I'll try my best to give a "cliff notes" summary of my past few days:

Saturday:  Day off...glorious!  Travelled west to Banos, a little hippy mountain town with streets lined with artisan shops, internet cafes, and replicas of the Virgin de Aguas Santas (Holy water?  looked more like algae infested bath water that would likely give 

you a good case of pseudomonas otitis).

  

My dear friend Sara came along...she's a Swiss nurse who's here at Hospital Vozandes for 8 months.  She's delightful, with her 

charming attitude and constant desire for adventure and fun (she even hosted a Viva Suisa! Swiss independence day party last week).  Highlights of the day?  A huge rainstorm that hit just as we were hiking the foothills of Volcan Tungurahua above Banos, taking a break at a restaurant/ resort overlooking the mountains and the entire town, a post-hiking meal of "cuy" (aka. guinea pig) for lunch! (tastes like salty chicken, but don't worry, I've heard it has no cholesterol), and in the afternoon, when the storm cleared, watching Tungurahua (volcano above Banos that erupted last Friday) spew out ash and smoke.  Needless to say, we both slept the whole way home on the bus.

Sunday:  On call.  And it was a rough 30 hours.  But at least there's never a dull moment, and no lack of variety in the patients we see.  Por ejemplo...Man comes in complaining of a bite on his hand... pulls out a giant jelly jar with the suspect.  A very large, very alive tarantula that had chomped his hand while he was buying bananas.  He was rather offended when I asked if he wanted us to call someone to come get the tarantula (a friend of Dr. Brice is a spider expert)... the patient wanted to take it home with him! 

A man was brought in by ambulance in the evening after falling from a waterfall.  He was cascade trekking with his daughter and friends and slipped, falling about 4 meters.  Surprisingly his only injury was his upper arm.  His humerus was broken in 3 pieces...it was an impressive broken arm! We took him for emergent surgery and found the radial nerve was overlying the splintered end of the bone.  We put a plate in his arm to help it heal, but the nerve damage will hopefully partially recover with time.  Besides those, we had 2 women in labor (one delivered at 1am), and a strangulated hernia that we took for (yet another) emergency surgery.  I can't complain of being tired though-- my resident was on call all weekend and slept all of 2 hours or so the whole time.  I took over for him in the middle of stitching up post-delivery lacerations because his vision started going blurry from lack of sleep.  Someone needs to create some work hour regulations here!

when it rains it pours

There's something about the rain here.  First of all, it's inevitable.  It rains nearly every day.  It's just something you can count on.  And because most of our patients come by foot, or by bus, usually when it's raining, things slow down a bit in the ER.  Unfortunately, the rain just lasts a short while... today it rained hard...and longer than usual... and things got really really quiet in the ER.  I even went home and took a quick nap.  Then it stopped raining.

Within a matter of 2 minutes after the last rain drop, the patients started pouring in the door.  "Doctorita, me puede atender?", "Doctorita, mi hija...", "Doctorita, doctorita, doctorita"... An emergency Cesarean section among them, several "non-emergent" emergencies, then a 14-yr-old boy with a snake bite.  Crazy.  When it rains, it pours.  Then after it rains...wow.

I've posted some long overdue photos of my trip to see monkey orphans... it's 2 guys who've rescued 22 monkeys whose mom's were killed (apparently monkey is a delicacy).

"eres gringa?"

Today in clinic a little girl looked up at me with curious eyes and asked "Eres gringa?"  (translation:  Are you a gringa?).  For those of you who have not traveled in Latin America, gringo is a term used for North American, pale with a camera around the neck, I'm going to bring a sombrero home with me type people... but somehow, in her sweet curiosity, it was very endearing.  I love how kids ask questions and say what's on their mind.

Another thing that I love-- the greetings here in Ecuador.  Everyone greets everyone else when they arrive, when they leave, even sometimes when they walk out of the room for a second.  In fact, one of the residents had a nanny here for her daughter, and the woman would say "Buen Provecho" (translation: bon apetit, enjoy, chow down) everytime she walked in and out of the kitchen during lunch... and that was at least 12 times per lunch.  That was kind of awkward.  But otherwise, I really like the greetings.  

I wonder why we don't have a cultural kiss in the US.  We just coldly, distantly shake hands, or give a head nod, or go about our business and don't greet each other.  Here it's the good ol classic one cheek kiss for everyone in the room to say "Good morning, goodbye, Thank you, See you tomorrow"... I've just grown to enjoy the affectionate customs of the culture here.  Watch out, I may kiss you on the cheek to say hi when I get back.  But seriously, I don't know if I'll ever be completely comfortable with my attending kissing me on the cheek to say, "Good work, clinic's done... now go home and read about polymyalgia rheumatica and VDRL titers and bronchodilators."  Still kind of weird to me.

discerning "yah" & the rule of 2's

Today was my first day to operate with the regular surgeon at the hospital.  I had been assisting Dr. Hammill, a visiting surgeon from San Diego, who was here for 3 weeks.  He was an incredible teacher, a genuinely kind person... he will definitely be missed here.  He was stepping in for Dr. Eckehart Wolff, the "orthopedic/trauma/whatever comes my way that needs an operation" surgeon, who's been here for 18 years.  Dr. Wolff is quick, and in the words of the Ecuadorian interns, is "very German".  I learned within the first few minutes that "Yah" meant cut, release, hold this retractor, move your hand, watch what I'm doing, and we'll have this operation wrapped up in no time.  The hard part was figuring out which one he meant.  

We started at 8am and had 6 surgeries done by 3:30!  Whew.  And they weren't simple either.  (A resection of a congenital pseudoarthrosis-- I'll post more about this later, a hysterectomy/oopherectomy, a giant incisional hernia, an inguinal hernia, and an osteomyelitis case, then after all of that, an emergency ruptured appendix turned generalized peritonitis with an incidental Meckel's diverticulum resection!)  It was a fun day.

hairy legs!

no lazy sundays in Ecuador!

So much for my "lazy" Sunday...  the past 36 hours has been CRAZY!  

1) Baby delivery total came to 3 with one more born in the wee hours this morning.  I took a quick nap today to catch up on my sleep bank that's been dipping far into the red and soon after I awoke, my post call adventure began...

2) My phone rang with an urgent call from "Alas de Socorro"-- Wings of Rescue, to let me know there was an emergency flight into the deep jungle to pick up 2 patients... did I want to go?  Of course!  I hopped in the tiny Cessna plane, room enough for the pilot, me, one seat behind, and a space for a patient to lay down behind the passenger seat.  WOW!  We flew about 40 minutes out from Shell to Makuma.  Pictures definitely don't do it justice... the sun streaming through to highlight shades of green and gray of the rolling rainforest blanketed hills and mountains jumping up from the deep green, the horizon of glimpses of jagged mountains peaking out between the clouds.  Think of "honey I shrunk the kid" flying closely over the top of a giant broccoli-- strange description, I know, and now I'm going to have to go to the fresh veggie market this week to satisfy my broccoli craving after 40 minutes of thinking of broccoli out and back!  It really was beautiful and relaxing with the hum of the engine, the warm sun, and not much civilization in sight.

When the plane started flying lower, I knew we were nearing Makuma, but there was NO runway in sight!!!  Just green green green with a few thatched huts in clearings here and there.  We circled around and I saw the "runway" finally, a dirt path carved out in a narrow clearing in the trees.  Rocks were placed at fixed intervals in the landing strip to slow the plane.  Surprisingly, it was a relatively smooth flight and landing!  

We stopped just long enough for the brightly clad Indians to come running out of the trees carrying one 60-year-old man who had fallen (I believe from a tree) and been impaled.  His abdomen was tightly wrapped beneath his shirt, so I wasn't able to see the extent of the damage... I was told that "his guts were hanging out" (sorry to be graphic), so he must have been a tough tough man to endure the flight sitting up if it was true.  The other patient was a young woman who had miscarried and was bleeding profusely.

Missionary Aviation Fellowship (the ministry that runs Alas) is a "good samaritan" organization, so we didn't attend to the patients during the flight (besides the fact that there wasn't room or equipment on board).  Just room enough to pick up the patients and transport them quickly to the hospital.  I think it's an incredible ministry!  What better way to use the skill of flying than to pick up gravely ill patients who would otherwise die in the jungle... most of the sites they fly to are at least a few days walk from help.

3) My first tarantula sighting!  On the side of my neighbor's house.  Take into account that because of the background, it's hard to tell the magnitude of this eight-legged creature.  But trust me, I wouldn't want it in my bed, or inside at all, or really anywhere near me.  It was at least the size of my entire palm, and I might even be underestimating.  Picture to come...

4)  While we were taking glamour shots of the fuzzy and intimidating arachnid, sirens sounded in the distance, and Dr. Brice's cell phone started ringing... a few teenage boys had been hit by a car while walking on the road and were just seconds away from the hospital.  I wasn't on call, but this is the kind of place that most medical workers in the area drop what they're doing and head for the ER when they hear sirens.  I saw one of the patients, sent him off for XRay, and finally made it home to relax, make some oatmeal raisin chocolate chip cookies, and post this much-needed update!  Whew!  What a day!

ready for tomorrow

Talk about a full day!  By 3pm, I had already delivered 2 babies, sutured up a machete-wounded hand, seen a handful of other patients.  Sigh.  It's good to have a break to sit down for a few minutes.  I have to admit, I'm getting worn out.  It will be nice to be post-call tomorrow and have a "lazy" Sunday.  A good nap, a run, reading (my latest book is "Freedom of Simplicity" by Richard Foster)... I think I'll borrow my neighbor's hammock for the afternoon.

early bird

It seems like every night on call has its own little thing to help get you through the night.  On Tuesday night, I was hoping it would be sweet sleep and dreams of good ol' Tennessee.... but instead it was sweet little Milena, all 3036 grams of her, born at 3:45am!  Her mom must have yelled at least 15 times "Cut me in half, get this baby out of me now!"  But in the end, all of her pain and effort was worth it for her beautiful little girl.  

I don't think the birth of a child will ever cease to seem a miracle to me.  To go from one minute with a woman lying in front of me, screaming in pain, with a gigantic convexity protruding from her abdomen, to the next minute with a slimy, but beautiful nonetheless, baby crying in my arms.  Miracle.  There's no other word for it.

My jungle education continues...

Yesterday I added yet another diagnosis to my list... the helicopter brought a patient from the jungle with a snake bite!  The 26 year old girl was working in her garden when she felt an intense sting on her hand... then noticed the 2 fang marks and her arm swelling up.  She didn't even see the snake, but there aren't many bugs that have fangs that big.  Thankfully she is doing very well-- a swollen arm and some pain, but none of the signs of severe venom toxicity.  

A great gift from God!

Today I praise God for His incredible goodness!  My sweet 4 year old friend Dax received a new liver this morning and is recovering from the transplant surgery now.  I wish I could be in Memphis to see him now... and to give him and his family a big hug.  His mom has made an incredible impact on me the past few years in Memphis.  I wouldn't give up my career for many things, but if you could promise me I could be like her--with as much patience and character and vision for what is possible in the life of a child (they have 4 precious adopted kiddos!) and ability to trust the Lord and stand strong in difficult situations-- I would give it all up in a second.  I'm so grateful for what she has taught me about what is REALLY important and what God can do when we trust him and sacrifice enough to allow him to do his good work!  Please say a prayer for quick recovery for little Dax.

That's what I call a weekend!

I don't even know where to begin describing the amazing weekend adventure I had... hiking in the jungle, climbing waterfalls, seeing beautiful plants and flowers and vines, swimming in a lagoon, white water rafting in a tributary of the Amazon River with rainforest trees along the banks and mountains on the horizon, spending the night in a jungle cabana house under a mosquito net... it couldn't have been much better.  

Hannah and Barbara (both physical therapists) and I hopped on a bus on Friday (the bus in Ecuador is a very frightening experience) to head to Tena, a town known for it's convenient proximity to the jungle and all things related to extreme sports (white water rafting, canyoning, jungle trekking, etc)...  I guess to sum it up quick, I'll make a top 10:

10.  Not flying out of the raft during the rapids... although our guide did flip me out of the boat on a calm part.  We wore wet suits, so the chilly water felt great!  (Although now I have the most remarkable wetsuit tan lines!  Ha!)

9.  Creature seeking at night with my super power headlamp... we saw spiders, a rhinocerous beetle, a tree frog, walking sticks, some really weird looking jungle bugs... I know I'm a nerd, but I loved bugs when I was little.  Just ask my sisters ("Know your insects").

8.  Reading in the hammock.  Whoever invented hammocks was a very intelligent person.

7.  Our bus didn't get stuck, break down, flip off the mountainside... we even had seats on the way home!  Standing in the aisle for 2.5 hours on the way there wasn't SO bad...

6.  Eating the fruit of the cacao tree.  The seeds are dried out and turned into chocolate, but I never knew the fruit part tasted soooo yummy.

5.  The lagoon was formed by a rainforest river tributary flowing down to meet with a tributary of the Amazon river... we climbed up stream and "rode the rapids" down into the lagoon.  So exhilarating!

4.  Our jungle trek guide, Solomon, and his knowledge of trees and plants and their uses for medicinal herbs.  Also his stories about the snakes (there are several very very venomous snakes that claim several victims a year).  One is called the "matacaballos"-- translation "horse killer".  Just to put it in perspective, the hospital I'm working in has a snake bite research protocol, so it's a fairly common occurrence.  Thankfully we didn't see any snakes at all (some of them, they say, if you see them you're too late... you can't run fast enough to get away!)

3. Being able to travel around Ecuador with 2 really unique and amazing women... Barbara is an Ironman triathlete,  (we're going to do a half-Ironman next spring in her home state of California)... Hannah is a sweet college student from England and taught me all sorts of new phrases I've never heard before...

2.  We hiked for 7 hours on Saturday and didn't see a single person other than our group... I'm convinced that God made the jungle for his own creative pleasure and glory.  It's growing and changing and existing in its grandiosity and beauty even when no one is there enjoying it.

1.  The best water pressure I've ever had in a shower was under the waterfall!  WOW, it was incredible!

Expectations, Traditions, and First Impressions

Not 5 minutes before, one of the attendings had just finished telling me that births here in Ecuador aren't so different than births in the US...  that's when it all started.  An Ashuar Indian woman had come in earlier in the day to deliver her 6th baby.  The patients who come in from the jungle have various traditions they carry out as part of the birth process.  For example, the mother or mother-in-law puts a lot of pressure on the top of the belly to try to force the baby to come down quicker.  Or another tradition, they send the laboring woman further out into the jungle where she digs a hole to fill with leaves and squats down over it to birth her baby there.  When the placenta is delivered, it is then buried in the hole as a marker of the birth place of the baby.  

Well, we certainly hadn't dug a hole or covered the ground in leaves, but there I was in the delivery room with my patient on her knees on the floor, her mother-in-law in the "heimlich maneuver" type position trying to push the baby out.  I tried (to no avail) to get the nurse to put the patient back in the bed and prepare the bed for the birth-- "wait," she said.  But I knew that being her 6th, we had no time to wait... and sure enough, within a few minutes the nurse was yelling, "the baby's coming out."  

So there I found myself, squatting on the floor in a pool of blood and amniotic fluid, with my head pressed against this poor woman's soon-to-be-unpregnant belly so I could catch the little one before his head met the cold tile floor.  I somehow delivered him just a few inches from the ground, quickly unwrapped the umbilical cord that was coiled twice around his neck...And the very strange experience ended with a precious life, crying in my arms, one leg of my scrub pants soaked in blood, a proud mommy finally ready to get in the bed to rest.  Welcome to the world, little guy!

beautiful

When I ask my patients how far away they live, usually I expect to hear 15 minutes, 2 hours perhaps, but 3 days, that was a first.  Her initial visit to the hospital, Gladys and a family member walked 3 days from a jungle area to arrive at Hospital Vozandes!  She is a beautiful 19 year old who has Langerhans Cell Histiocytosis... a very, very rare type of blood cell disorder.  She's been in and out of the hospital for about 8 months.  I went in to change her bandages today and we chatted, she smiled the entire time.  Her prognosis is pretty good with the proper chemotherapy treatment, which she's receiving at our hospital.  I've posted a picture of her with Carolina, another one of the interns.  (and one with me)...And yes, Gladys smiles like this ALL the time!  

The other picture is my little town, Shell, with the towering Andes draped in clouds as the backdrop.  Hopefully on a clear day I'll be able to get a picture of the snow-capped volcano that can be seen occasionally on the horizon.

...

a precious little boy with Down's syndrome who came into the ER today

simplicity and satisfaction

Working at the hospital, and living here in Shell for that matter, has become significantly easier over the past several days.  It's amazing to me how quickly after arriving I became so overwhelmed I wanted to give up... and how quickly it all changed.  The Ecuadorian interns have taken me under their wing to help me with abbreviations, the different equipment here, and some of the more colloquial phrases.

I was on call last night and got to first assist on an emergency appendectomy... so much fun!  After the surgery they told me to wash my gloves and leave them on the counter to be sterilized and reused!!!  Yuck.  I know they really sterilize them well, but something about it seems SO wrong to me.

I'm getting more used to the town.  Shell is about 5000 people total and there are about 25 missionary families included in that number.  It's a simple town, but I still feel like I have everything I need.  I'm learning a lot about the value of simplicity these days.  The fruit and vegetable market (so cheap and SO yummy), the meat markets (I refuse to buy a chicken that's been hanging all day in an open window, though), several restaurants, an internet cafe that has a pet monkey.  Oh and there's a big swinging bridge over the ravine.  It's probably about 50 meters long and creaks the whole way across.  It's beautiful though, so I'm trying not to think about what would happen if it broke while I was walking on it :)

I don't know what to say other than I feel very satisfied right now...doing what I love, serving people who need it, learning, feeling useful, staying busy, crossing cultural barriers, opening bodies to heal infection and disease, and knowing all the time that my sovereign Lord's hand is over it all... He's given me the privilege of being satisfied in my work!  Hallelujah!

diving in head first

Just a few days in and I've already seen so much.  I guess it helps that I'm on call q3 (every third night for those non-medical)... It's a steep learning curve.  I came in semi-confident in my Spanish only to be blown away by rounds-- imagine speed-talking medical terminology-- sometimes difficult to understand in English let alone Spanish.  But things I took for granted in Memphis take a lot of time and effort here (doing my own EKGs, ordering labs one at a time instead of just CBC, CMP, etc...).

We see such a variety of patients, some of which I thought were just examples in antequated textbooks.  Leptospirosis, for example, would not be on the top of my list for diagnoses my patient with a fever and body aches.  I wouldn't have even thought to order the test for it.  I was humbled.  I was wrong.  And leptospirosis was positive.  

Simple things like equipment that works and specialists in every possible disorder imaginable, are unfortunately not widely available.  A woman came rushing in this afternoon carrying her precious 5 year old, yelling "she needs oxygen, please!"  The valve had broken on her home O2 tank and she had no way to fix it.  The little girl has end stage osteosarcoma (a type of bone cancer) that was not cured by amputating her leg or chemotherapy.  She held my hand and her mom gushed with gratitude.  

Thankfully I've had no run- ins with snakes or tarantulas yet.  I shouldn't say that too loud.  But the humidity is killer.  Everything is damp-- book pages feel soggy, the salt clumps in the salt shaker.  There is even a "dry closet" in my apartment that has a light bulb that stays on constantly to generate heat to dry the air inside.  People think of Ecuador as a tropical place, which it is, but tropical doesn't necessarily mean warm.  It's constantly cloudy, rains about 10 hours a day, and is in the low 60's.  A nice break from 90-100!

my downhill arrival and guinea pig xrays

My first rainforest rain tonight... it's refreshing. It's humid (like Memphis) but cool (unlike Memphis). And the view from my front door is nothing like Memphis at all-- it's the foothills of the Andes caped in clouds and the jungle trees making their way up in elevation to meet with the heights. I don't think I'll mind this view for the next two months.

I landed in Quito last night (elevation 9000ft), and rode to Shell today-- a 5 and a half hour trip with a charming taxi driver named Maximo and a missionary nurse who's been working in the deep jungles doing health education for 29 years. Shell sits wedged between the Andes and the Amazon rainforest at ~3500ft, so our trip today was downhill the whole way. The mountains were beautifully patchworked with crops up to the harsh cloud line, which I'm told was hiding the snow capped volcanic peaks.

Already I've been warned by many that Ecuadorian medicine involves many things never before seen (or even thought of) in the States. For example, the "jungle XRay". Picture this... your patient is in an accident, probably many fractures, maybe even some internal bleeding, and there's no XRay machine to be found for hundreds of miles. That's where the guinea pig comes in. Yes, guinea pig. The guinea pig, who I'm sure would rather be the first subject of a dangerous research study, is then taken and rolled with great fury and force over the patients entire body. Needless to say, the guinea pig dies during the process and is then cut open and carefully dissected... wherever the guinea pig has internal injuries and fractures is the source of the patients pain. (Somehow I think that maybe most of these patients are diagnosed with far more injuries than they really have, based on the guinea pigs appearance anyway). And this is why I don't recommend going to a jungle shaman for xrays... but the next time I'm having trouble with long lines for the xray machines at the Med, maybe I'll stop by PetSmart to get the job done a little more quickly?