Janice Yip '15
Student Director for Nicaragua CCESP
Major: Computer Engineering
Hometown: San Jose, CA
For as long as I can remember I have wanted to be a physician. Coming from a family of doctors, many have often said that I am merely following in footsteps. However, because of this criticism I have examined and re-examined my plans multiple times. And yet, each time I always still want to become a doctor. As I go further along the path to medicine, the road has begun to look much longer and harder than I previously had thought. Lately, the realities of pre-med courses, medical school applications, and the MCATs have all awakened fleeting thoughts of alternate careers. However, I now see the road to medicine and the profession through slightly different eyes, thanks to a gained maturity and the experiences of the past two months. My conviction and inspiration to go the medical school certainly has been revived as well as the type of physician I see myself growing into.
My off-term was spent in a very interesting and unique way thanks to the D-plan and the Tucker Foundation. Instead of getting a traditional internship, I traveled to both Ecuador and India. Before I left for Ecuador, I also went to Nicaragua on the Tucker Cross Cultural Education and Service Project, something that also added to my overall experience.
I went to Ecuador with the non-profit organization Cosmic Volunteers. They had arranged for me to live with a host family and work in a local hospital's Emergency Room. This was about all the knowledge I had boarding my flight to Ecuador. I also had barely spoken any Spanish in nearly two years. Needless to say, I was fairly nervous. I arrived first in Quito, the capital of Ecuador and was immediately taken aback by the city's altitude and beauty. Nestled in lofty mountains was a vibrant, modern capital city full of culture. Patricia from Cosmic Volunteers helped me get settled for a day and the next day sent me Ambato where I would spend the next month. Ambato is a medium sized city, the fourth largest in Ecuador, with a small but congested downtown or "centro" and numerous suburbs sprawling up the surrounding hills. To be honest, it looked a lot like southern California with plenty of rich flowers and landscaping interspersed with pockets of bustling city life. My host family was a grandmother and grandfather, Doña Fanny and Don Jorge, and their daughter Soledad. Downstairs also lived their son, daughter-in-law, and baby granddaughter. To my relief, they were very nice and welcoming, having hosted many other students.
I visited the hospital for the first time that day. Ambato Regional Docente is the largest public hospital in Ambato. After passing through security gates with armed guards, the first thing you meet are the throngs of Ecuadorians, both natives and locals, most waiting for family or for care themselves. Pushing through the crowd, I came upon a large, run-down building in worse condition than probably any hospital in the US. The ER consisted of five rooms. The first was the main room which was a triage area with one bed, one desk, and 3 curtained areas for general patients. There was also a room for sutures, OB/GYN, observation, and critical patients. The first day I met the two people that would make the greatest impression on me: the head of the emergency department, Doctor Vinueza and the chief nurse, Esmeralda. Throughout my time in Ambato Regional, both were extremely excited and eager to have me there and for me to learn all that I could. Though I was only an EMT with limited clinical knowledge, they both made me feel important and vital to the system and helped me learn a lot.
My daily schedule involved getting up and walking to the nearest bus stop. The city bus system in Ambato is an experience to say the very least. Getting on and off are generally done while the bus is still moving and the entire ride costs about 18 cents. I would get to the hospital everyday around 7:30am just in time to catch the nurses from the night shift and hear the interesting cases. The first few hours were generally pretty slow as the city generally doesn't start working until around 9 or 10 am. In the mornings, the nurses and I would oftentimes make supplies for the day. We would make our own cotton balls and swabs, alcohol wipes, bandages, IV preps for infants, and other various supplies that were needed. My spare time was often filled with restocking the rooms and looking up medicines in the drug book that we had used that day.
As Regional was a large government hospital, the patients were fairly poor and oftentimes were native Ecuadorians. As patients came in, they would wait in the hallways until they were called into the triage area, generally in whatever order the triage nurse desired. Critical patients that came in by ambulance would go directly to the trauma room, though with the weak EMS system, ambulance patients were very rare. I would triage the incoming patients and start a "chart" which was a single sheet of paper. I would take the identifying information and vitals on all patients including pulse, blood pressure, respiratory rate, temperature, and weight. The majority of medical patients coming into the ER were pregnant women and young children; trauma patients were generally men with work injuries from farming and building professions.
After triage, patients or family members were sent to pay their bill, generally around $1 for most medical consults. A doctor would do an initial workup of the patient and then order the appropriate tests and medicines. It was interesting and different to watch the diagnostic practices of the physicians there. Most diagnoses were done purely based on physical findings and the patient's history, which was generally unreliable. The patients themselves would have to leave the ER and go to x-ray or the laboratory for their tests, which they also paid themselves. If the patients required any medicines, even intravenous ones, they had to go to the pharmacy to buy them and then bring them back to the ER. Patients also had to bring any instruments that were required for simple procedures including IV and suture kits. I was always uneasy sending a vomiting patient to go buy his own IV kit so he didn't get dehydrated, but the patients found the practice normal. I have never seen such strong and pain tolerant patients before in my life.
I have to admit that the most interesting patients in my mind were the trauma patients, but there were also many others that deeply affected me. Nearly 1/3 of our patients required sutures. For the first two weeks, I would assist on all sutures by prepping the patient and kit and assisting the doctor during suturing. The doctors were always very thorough in explaining what they were doing and the purpose of every step. By the last week, I had sutured two patients with a doctor's supervision. I was definitely apprehensive at first plunging a needle and thread into a patient's open wound but was very proud of my work and what I had done for the patient by the end. I would first numb the edges of the wound with lidocaine and then using a suture needing and vicryl, would suture the wound. Hygiene in Ecuador, especially among the poor, is not good; therefore, maintaining a sterile environment and properly cleaning wounds is crucial to prevent infection.
Few other trauma victims also came into the ER. One of the most disturbing days involved a construction accident with a 19 year old boy, his father, and his 15 year old friend. Early in the morning we hear the rare sound of sirens from an approaching ambulance. As there is no communication between the sparse EMS system and the hospitals, ambulances arrive unannounced. The 19 year old had been electrocuted and with only a small entry and exit burn, had no other visible injuries. However, the voltage of the electricity was very high and he arrived dead on arrival. One of my jobs was to keep reporters and family outside of the trauma room; pulling the boy's sobbing father off of his dead son's body was one of the hardest things I have had to do in my life. In between tasks inside the trauma room I could glance up and hear the father's sobs mixed with vain pleas for help. Even worse, given the delayed EMS response and transport with the facility's limited abilities and supplies, resuscitation efforts were not even tried once the boy was confirmed dead. That was the first "newly" dead body I had seen and needless to say, it shook me up a lot.
Unfortunately, later that day we had our second DOA. A young woman ran into the ER wailing that her baby wasn't breathing. All of us cringed and went to see her 3 month old baby. I walked into the room first and saw a tiny baby that already had a bluish tinge, not a very good sign. When I got there, the baby had no pulse and was not breathing. I immediately started CPR which we continued for 20 minutes with no response. The baby had been dead long before arriving in the ER. I was shaking all night long after that day. It was really hard to see two young people die and there was nothing any of us could do. I realized that in this and many third-world countries, death is a very accepted part of life. The American mentality and healthcare system has greatly skewed the natural cycle of life and death, as oftentimes people and bodies are pushed to cheat death time and time again. Though it is hard to accept death, sometimes it is natural and unavoidable; nowhere in the world can a doctor play God.
With medical patients, my job started with basic observation with the nurses and physicians. However, after careful explanations and supervision, I was soon doing many basic tasks that would otherwise overwhelm the nurses. I would administer intramuscular injections, check blood glucose levels, and start IVs. Many nurses and patients would mistake me for a medical student or doctor (though in most patients' mind in Ecuador, the two are the same thing) with my mandatory white lab coat. On one hand, it was easy to blend in and seem appropriate while on the other hand, it was difficult to Oftentimes, I found that the trust placed in doctors and nurses was extraordinary, certainly more so than in the US and I had to be careful how I used that trust.
In addition to all of my daily duties in the ER, sometimes I was able to participate in other areas of the hospital. Oftentimes, I would act as a runner between the laboratory, x-ray, and ER, checking on films and transferring patients. Furthermore, outside of my assigned internship of Mondays to Fridays, I came in a few Saturday nights to catch the busy action. One of the most impressive things about the hospitals was the educational component. The hospital staff ran weekly seminars and talks given by physicians in their field of expertise. Also, the ER held monthly meetings with the entire staff where a physician in neurosurgery or another relevant field would give a talk on how ER workers could better treat brain injuries. I attended many of the hospital seminars and one of the ER meetings. It was both informative and encouraging to see the intense desire and continuing and goal of these physicians to continue learning and providing the best care to their patients.
Overall, my experience in Ecuador was interesting. It was fascinating to see how a hospital runs efficiently and skillfully with very limited resources. In the end, medicine is medicine and throughout the world it is the same. Obviously resources and location are both driving factors in the level of care. However, the dedication and commitment to medicine and taking care of people is the same everywhere. Not only did I learn valuable and interesting skills, but I realized the true responsibility and dedication that must come with those skills. As I take steps into the medical field, I think the most important lessons I will learn are not the physical procedures but rather the newfound responsibility and respect that I have further developed for the medical profession in every area of the world.
My experience in India was completely different, though eventually had the same impact on me. I went to India with a non-profit organization based out of Atlanta, Georgia called Himalayan Health Exchange. Every few months, they take a team of 4th year medical students, doctors, other healthcare professionals, and few non-medical support personnel to different regions of northern India, particularly to the state of Himachal Pradesh. The organization and teams work with the government of India to set up and run short 2-3 day clinics in different rural regions of the state and Himalayan range. In addition to the US personnel, the team is generally joined by various local physicians that aid the team in translation and education regarding regional diseases and cultural practices. Most of the employees of Himalayan Health are from Himachal Pradesh and were thus good resources throughout the trip.
Our trip was the first trip of its kind to the region as HHE had never done a traveling clinic before. The team consisted of four fourth-year medical students, one full physician, two third-year residents, and three non-medical support personnel. At each location we would arrive early in the morning and set up camp. We would generally be met by hundreds of villagers who oftentimes had walked or been bused in from outlying communities, sometimes up to 100 miles away. After trying to hold back the crowd as best we could, we would start running the clinic with a triage station, a pharmacy, and four to five medical stations with some designated for pediatrics or OB/GYN specifically. For the majority of the time, I ran either the triage or pharmacy station, taking general vitals and history or filling the doctor's prescriptions with the limited and oftentimes scarce amount of medicine we had. For the other times, I would stay with a medical student or physician in a station helping with the physical and diagnosis of the patient.
At the first clinic site, we worked out of an existing clinic site that was staffed by a doctor posted by the government and a small, generally illiterate staff. Though the facilities were beyond horrendous in their hygiene, upkeep, and available resources, I was still amazed at the staff. Instead of meeting a depressed, defeated staff, we saw a group of people honestly thankful for at least the facilities they had and took their job of serving and protecting their small community very seriously. The doctor had implemented regional outposts of his main health station for outlying families. Furthermore, he had implemented vaccination and record-keeping (of births, deaths, illnesses, etc) systems that rivaled ones I have seen in first world countries. Each day we saw hundreds of patients with problems ranging from simple upper respiratory infections to carcinomas and congenital abnormalities. One of the most frustrating things was telling people that they had a serious problem and there was nothing we could do about it. We saw one boy whose foot was so gangrenous after an accident that we knew it would have to be amputated. All we could do was to give him a referral and money to get to the district hospital for the surgery. Even then, it was doubtful if he would actually be able to go or not. On the same hand, we saw a gentleman whose lower eyelid was drooping about one centimeter away from his eye. Luckily, on our team was an ophthalmic-plastic surgeon who performed the necessary surgery and saved the man's eyesight.
Other clinics were similar though each location was unique. Our other locations included rural health posts, monasteries, a private home, abandoned hospitals, and wherever else we found people needed our care. One of the more disturbing things we found was not necessarily the lack of care, but the level of care. In many health posts, we found men with barely high school education and unofficially trained as pharmacists calling themselves doctors and treating patients as if they had a medical license. The first rule of medicine is to do no harm. Even when our doctors did not know the proper treatment or diagnosis, they simply said so as opposed to causing harm by lying to the patient. We tried to bring some basic education to the health care providers every place we visited about basic care that even lay people could provide without a formal medical education. However, as opposed to Nicaragua, the "physicians" in India were very hostile and adamant about their qualifications to practice medicine. It was really hard to leave those towns knowing that the people's care was left in the hands of an unqualified person making poor decisions.
Some of our other clinics were certainly better received. One clinic was set up in the personal home of the ex-health minister of the state of Himachal Pradesh. The minister and his family were unbelievably welcoming and caring, opening their home to thousands of patients each day in order to provide better care to the region. Everyone was so grateful, that seeing a record 546 patients in one day with a team of 7 was quickly forgotten by the looks on all the patients' faces.
In another clinic, we were working in a particularly rural and poor area of the state. Most of our patients had never seen a doctor or hospital in their life. The absolutely most spine chilling case I saw in my life was a mother who brought in a wrapped bundle in her arms. The bundle turned out to be a boy of about 6 years old. Upon first triage, I thought the child was badly burned. I could not see very clearly but knew immediately that this little boy was very sick and needed immediate attention. I brought him directly into the tent with our attending physician, a resident, and one of the medical students. The doctors also thought that the child was burned or injured in some way. However, upon further examination and speaking with the parents, it was clear that his condition was not external, but rather internal. It turned out that the boy had a rare skin disorder called xeroderma. Patients with xeroderma are lacking a molecule in their skin that processes UV light and thus, are hypersensitive to UV light. Victims must be kept out of sunlight at all times to prevent excessive and painful blistering and sores on their skin as well as further metabolic malfunctions internally.
We asked the parents whether they had ever seen a doctor and they said that they had been into the district hospital twice and both times were sent away with a cream saying that it was only a superficial skin condition. We were the first people to tell them the disease their child had and explain it to them in detail. However, the worst part was that the little boy was far beyond our help. Half of his face was eaten away with scarring and blisters. Sores and bloody pieces of skin barely covered the rest of his limbs. If at a hospital, his left leg would have been immediately amputated. He had already lost both eyes, leaving sunken in sockets that would occasionally spill out tears of pain. Our attending estimated he would die within the next month from sepsis (systemic internal infection). We sent him to the district hospital for further wound care and pain medicine, but spent 2 hours crying with the boy and his parents. If in the United States, that little boy would have been diagnosed within a few months of birth and could lead a long and fulfilled life without any pain from this otherwise crippling disease.
Camp after camp, we saw patients that were both beyond our help and those whose lives we saved. A woman came in complaining of a skin infection under her breast. It was a carcinoma that was so advanced that it had eaten its way to the surface of her skin. A man came in complaining of blood in his stools. We diagnosed him with a tear in his intestinal tract and sent him to the district hospital for surgery that would most likely save his life. A baby came in with a spine so out of shape that without a very expensive and dangerous surgery, her spine would eventually crush her internal organs and kill her. A child came in with a simple viral infection and one of our doctors picked up a small, rare heart defect upon examination that could save his life if now properly diagnosed and treated. If I can say one thing after those cases that pull your heart in absolutely opposite directions, it would be that medicine is fickle and having the gift and responsibility of medicine forces you to bend with it. There is no way to save the world, but change is simply made one person at a time knowing that you care and for that moment, you are there to help them make their life better and healthier. And if you for some reason beyond yourself cannot help them, you will be there to make their final journey more safe and comfortable.
The greatest satisfaction of this trip did not necessarily come from treating patients or even seeing and learning more medicine than I will until third-year medical school (though that was also very cool!). However, it did come from the people I met across the world and the common bond and theme I found throughout villages in India to hospitals in urban Ecuador. No matter where you go, people are the same. They still love their family, care about safety, and worry about the future. As a doctor, especially practicing international medicine and healthcare, it is vitally important to take the responsibility medicine gives you incredibly seriously, no matter where you are. To recognize the similarities and differences in every situation is important whether you are making international healthcare policy or treating a villager in India. I will never approach medicine or even people the same way after these trips. They have become more than trips or off-term activities; they have become ingrained as part of my life, who I am, and who I want to be as a doctor.
Addendum: I want to take a minute to especially thank the Tucker foundation and fellowship for allowing me to have this life-changing experience. Furthermore, the people of Ambato and Himachal will forever be in my heart and hopefully, will soon again be in my life. Thank you for opening your homes, hearts, and lives to a naive college student. I am forever indebted to everyone who allowed me to have these experiences.
Last Updated: 12/1/08