Reflections From Ecuador

Over spring break 2017, 16 medical students, one resident and three faculty physicians from the Lewis Katz School of Medicine at Temple University spent 7 days in rural Ecuador on a medical mission trip.

The student-run Temple Emergency Action Corps (TEAC), founded in the wake of Hurricane Katrina by Dr Zoe Maher, an LKSOM alumna, assistant professor and current Temple trauma surgeon, organized the trip. Each year, TEAC travels to an area pounded by a natural disaster or battling a chronic lack of resources, and teams with a local organization to provide care.

The Greenfield Foundation and Dr. William Greenfield, a LKSOM alumnus, fund the trip.

In many ways, the week in Ecuador was transformative. What follows are short reflections by nine students and one resident, and photographs by medical student Eric Curran.

1) Tyler Wilps, M1

Traveling has always been about connection for me and things were no different when serving in Ecuador.

I felt connection to the Ecuadorian Landscapes. The vastness of the Andes Volcanoes was humbling and it produced a piercing silence that drove my mind to introspection. On the bus ride to the clinics we were surrounded by green mountainside tiered for farming and radiating the life of Ecuador. The beauty of the natural world and the knowledge of where I was heightened my sense of connection.

I felt connection to the people of Ecuador. Chasing a soccer ball with a group of children from the mountain communities we served made my heart race and transformed my worries to exhilaration and laughter. Running and laughing is a powerful healer. And as our doctors showed compassion in healing their patients, I again felt connection. The care of a 90-year-old Ecuadorian indigenous woman brought me to tears. A lonely elder, her daughter had moved away to the big city. She needed to be talked to, she needed to be cared for, and she needed love. With their simple touch and words of understanding, our doctors showed me how compassion and tenderness can be the greatest treatment, and that at the root of it all there is connection.

2) Eric Curran, M1

I worried that once I was back in the library, sifting again through the details of neuroanatomy, I might start to forget those I met south of the equator. I didn’t want to leave the people, experiences, and lessons at the boarding gate. So, when I wasn’t seeing patients, I slung two cameras around my neck and started framing ways to remember. One was a digital camera, the other a 33-year-old film camera. Intentionally, I often directed their lenses toward contrasting subjects.

Through the LED-lit viewfinder on the digital, I would capture the hustle of our team each day.

We cover a shaky table with medications, ready to be dispensed from our make shift pharmacy. Click. Our team assesses vital signs on a growing line of patients. We rearrange two dozen benches to function as a waiting area. Click. A doctor asks a patient, with the help of two translators, “How long have you had these headaches?” A tree blocks the one road leading to the day’s clinic site. We leave the bus and heave the trunk out of the way. A group of us in sky-blue scrubs passes a soccer ball back and forth to school kids wearing matching red uniforms. Click. The digital’s automatic focus and exposure control, paired with a high capacity memory card, made it easy to snap away.

But in quiet moments often tinged with emotion, I would take the lens cap off my film camera and peer through its scratched viewfinder.

My thumb and index finger twist the scene into focus. I set the exposure and aperture, hope, and finally release the shutter. A small bicycle sits on its side in the mud. Focus, set, release. An elderly man on a horse pauses to look in my direction. Through cracked glass, I see a student grasp a patient’s hand in a gesture of comfort. A paint chipped classroom desk sits on a rooftop, gazing at the green rolling hills. Next to a pile of dusty bricks, a dog raises its head in sleepy curiosity. Focus, set, release. A young boy in a backwards cap asks for a photo. I direct the film camera towards the water-filled crater of a dormant volcano. The green beauty is overwhelming. A battered red truck sits in the sun, its engine ticking as it cools. A wooden rosary dangles from its rearview mirror. A string of colored, ripped tee shirts hang out to dry. A young boy with an ice cream cone looks up at me. Focus, set, release. The nature of film photography forced me to slow down and decide what to capture.

Within a few days of our return, I had a memory card in one hand and sleeves of negatives in the other. I held our entire service trip in the form of photographs. The people, places, scenery, food, and sunburns we encountered in Ecuador were all there. So too were the confusion and excitement, helplessness and happiness, sadness and gratitude. Each and every conversation I had with a patient was humbling. Back home at our academic medical centers we have gamma knives, catherization labs, fully stocked pharmacies, and dozens of medical specialties available to help treat patients. These things are not available in rural Ecuador. Yet the patients we met seemed grateful just to have someone willing to listen. They spoke of aches and pains, coughs and headaches, growing pains and old age. We did all we could to help. At times it did not feel like enough. Still the incredible people we met would say to us “gracias, gracias,” in a tone of relief. Sometimes, it seemed the practice of listening and showing compassion had its own way of healing. In times like this, I learned as much about medicine as I learned about others and myself. I don’t think I will forget these lessons, but should I lose sight of what matters, I have these photographs to serve as vivid reminders.

3) Nicole Kus, M1

I traveled across the equator to learn a lesson I hope to remember for life. One day, in the remote mountain clinic in Ecuador, where I traveled on a medical mission trip over Spring Break, I was working on intake. We had a patient complaining of fatigue, shortness of breath, what more experienced medical students were already calling “the usual.” Before we started the physical exam, a student next to me predicted the cause was probably old age, and I agreed. However, when we examined the patient, we heard an obvious heart murmur. Further examination showed us that the patient was in severe congestive heart failure and he had been living like this for over 30 years.

I was shocked. I felt guilty that his concerns were so easily disregarded, when clearly this man had been suffering. This memory will always stick with me. It taught me that outside experiences and preconceptions should not interfere with listening to and caring for each patient with dignity and respect.

4) Marlee Milkis, M1

On the last clinic day in Ecuador, I worked at the gynecological station. Since the clinics were usually held in local schools, this was often a classroom separated from the rest of the building. In order to see as many patients as possible, the room contained the two doctors, two med students, a nurse, two patients being examined, and one patient waiting. The situation was far from the “comfort” of what most American women experience, however, most of the women gladly stripped down, put on a gown, and hopped on the exam table. They were such troopers about it all that I honestly hadn’t thought much about their privacy or dignity until one of the last patients of the day.

At about 2pm, a young woman entered our make-shift exam room. She was probably in her early-to-mid 20s, with jet-black hair, beautiful bronze skin, and tentative body language. We exchanged a few smiles when she first came in. She was across the room from me as the other medical student took her vitals and asked her a few questions. She was timid, and I could sense that she was uncomfortable, but she seemed interested in meeting my glance. The other student showed her to the “changing area” behind a bookcase in the corner, and I motioned her over to my chair once she came out.

I took a few years of Spanish in high school, but that knowledge has long since been replaced by physics equations and biochemistry pathways. I greeted this young woman and exchanged what pleasantries I could. Suddenly, she leaned in close and whispered something to me in Spanish. I couldn’t understand a word, but also couldn’t shake the feeling that what she had to say was important. As we waited for the doctor to examine her, I was able to grab a Spanish-speaking member of our team and ask her to interpret. I found out the patient had only had one other pelvic exam in her life and was feeling uneasy about this one. She was also uncomfortable with the other people in the room. I had the interpreter reassure her, explaining that the way she was feeling was valid and that we would try to make her as comfortable as possible.

I explained the situation to the doctor and was able to hold the young woman’s hand during the exam without feeling like I was over-stepping my bounds. After the exam, she thanked us, and we exchanged one last smile before she left. Among many things, this experience taught me how much I value the ability to make deeply personal connections with patients, and how important it is for a patient to feel comfortable with her doctor. Consequently, it has inspired me to spend my summer improving my Spanish. It may not help me reach every patient, but it’s a start.

5) Kimon Ioannides, PGY-1

I was absurdly happy in this photo. But it’s funny I threw on a pair of gloves before sharing some love with this puppy. I’m not sure if I was afraid of fleas, or if the medicalness of them somehow made me more comfortable. Our work ties us to the communities we care for, whether it’s in Philadelphia or Ecuador, but it also creates a distance, and that becomes a weird symbiosis. It’s important to have feelings about patients — compassion comes with frustration, just like with family — so we have to be aware and careful with those feelings. It takes time, energy, and vulnerability to develop that healthy relationship with a community, to feel close with our patients, in Riobamba province or in North Philly. But it’s a lot faster (and simpler) with dogs, and I wonder if that’s part of why I felt so drawn to all the strays. As an emergency room doctor, I’m always trying to understand my patients better, and not just by improving my Spanish, and I’d like to think this little guy helped with that.

6) Rachel Ragheb, M1

A woman walked in from the overcrowded waiting room, leading her 16-year-old son to the chairs before us. The boy was timid and quiet. We greeted them both and the boy sneaked a smile. The mother stated that her son had terrible stomach pains and headaches that occurred spontaneously. We learned from the mother that her son was already receiving medication for the headaches and stomach pains; however, when we asked him questions, he would not respond. The mother explained that he was unable to speak. Despite many lessons and classes, she said, the boy still could not write. She said he was termed an “intellectual special.” We asked her to explain this to Dr. Vega-Sanchez. Then the woman asked the doctor when her son would be able to speak or write; she needed to make sure he could take care of himself when she was gone. Dr. Vega-Sanchez gently responded in Spanish, “I’m sorry, but your son will never be able to speak or write. This is not something that can be cured…” Dr. Vega-Sanchez explained to the mother that her child would grow normally, but he would always need someone to care for him, to attend to him. Shock spread over the mother’s face. She looked over at her son, with her temples tense and pain in her eyes.

…my mind spaced out…my heart sunk in my chest. This woman came with the simple goal of making sure her son would be okay after her death, only to find that nothing could be done to help him.

How did no one tell her before this point? How could there be no communication to this poor mother and her son? He was 16 years old, 16 years and nobody told her.

…And I couldn’t do a thing.

7) Greg Angelides, M1

Working alongside upper-year students and attending physicians during a week of volunteering in Ecuador, I learned more practical doctoring than I had over the preceding eight months of medical school. I came to appreciate that although my medical knowledge is still in its infancy, I can have a measurable impact as a productive member of the medical team.

For example, a patient complaining of abdominal pain 2 months after giving birth to her fourth child came to see us on recommendation of the gynecological team. We went through a few rounds of questions, translations and briefly consulted the gynecologist to confirm her pelvic exam had no findings. In a roundabout way, we came to appreciate that her pain seemed worse when she was breastfeeding but she had not experienced this issue after her previous pregnancies. Although I had no prior experience with what she was describing, I pieced together her symptoms with my basic understanding of hormones and their effects, which I had just recently learned in a physiology course. I postulated that an increase in oxytocin levels while breastfeeding could be triggering uterine contractions causing her lower abdominal pain. It was quite memorable to come up with an explanation of a condition I had not yet learned about, but could understand through peripheral knowledge.

Turns out it’s quite common, not too serious and can manifest after multiple pregnancies due to a thicker uterine wall. We were able to put her at ease and counsel her on her concerns with breastfeeding feeding going forward and its importance in her infant’s health. We also set her up with a place to go if the pain did not subside as expected. Though this patient’s condition was less severe than most we saw, I left Ecuador knowing the trip had a lasting impact on me personally and on those we treated and connected to care.

8) Erika Chaconas, M1

Our bus traveled for hours on winding, one-lane roads rising into the Andean Mountains on the second day of our medical caravan. Yesterday we saw over a hundred people, many of whom were elderly, with ailments resulting from years of strain working day after day in the fields. Yet today was different — I heard stories from men in ponchos and women wrapped with bayetas who didn’t complain of physical aches. I listened to the struggles of a teenager, fidgeting uncomfortably before me, who felt burdened with overwhelming fear of expressing herself, and the stresses of feeling alienated among her peers. I spoke with a mother, gently prompted by her concerned husband, who with wide, sad eyes described many months of fatigue, disinterest, and disconnect.

We listened, we asked questions, and we tried to counsel, but ultimately these very real problems — illnesses that can be just as debilitating as those of muscle aches and pains — left me wondering what effect our brief intervention could do. How do you provide sustainable pain treatment and rehabilitation for patients with decades of strain to their bodies? Can the people of these rural villages even get access to support groups or counseling or medications for mental illnesses? Options for treatment and access to support for these issues is lacking even in our highly resourced society at home. How will they be cared for beyond our time here?

9) Drew Zebley, M3

After riding in a bus for upwards of three hours en route to our clinic site for the day, we had to leave the bus behind. The road to this particular site was especially difficult. We drove up a mountain, down a mountain, winding our way through fog until finally the bus could go no further. However, while the road was unwelcoming, we were met by a friendly man atop a donkey who could not have been happier to see us. Though we did not understand each other, he rode alongside us as we trekked from the bus to the site, another 15-minute walk. He stayed on his donkey as we set up the clinic, as if supervising everything we were doing.

Marlee and I prepared to see our first patient. Who walks in but the man who had greeted us at the bus. He was short and walked hunched over a cane, and was so excited to be seen. He shook our hands with a big smile. As we began the history and physical, we learned this man was one of the community leaders who had worked all his life as a farmer, like most of the people in the town. He was in his early 70s and had not seen a doctor in many, many years despite living with chronic knee pain. There was little we could do for him. In the states, he might be a candidate for knee injections, joint replacements, and a comprehensive pain management regimen. But those were not options for him. Instead, we were able to give him some topical cream to apply to his knees no more than twice a day that would last him maybe a month We also told him about some of the alternative therapies for joint pain that one of the Ecuadorian doctors taught us.

It was humbling just to talk with him. He understood when he came to the clinic that we could not cure him of his knee pain. He came to check on this group of doctors and students who would be treating his community. Many of these communities are composed of indigenous peoples who are not accustomed to being treated with dignity by the Ecuadorian medical establishment. It takes a great amount of courage on their part to let a group of outsiders into their communities, and we were honored to have been welcomed.

10) Yuri Takabatake, M1

A line of women dressed in vibrantly colored traditional garments waited in front of our OB/GYN clinic every day. Rain or shine, patients waited for hours. For many, this was their first time ever receiving a gynecological exam. One clinic day, I had the privilege of talking to some of these women while shadowing Dr. Horton. They expressed concerns of a broad range, including pregnancy, fertility, cancer, infections, and societal expectations toward women in their village. One woman in particular disclosed that she had not been able to conceive any children since she started trying after getting married few years ago. In her indigenous community, a woman was expected to bare children as soon as she was married. Consequently, she blamed her own body and felt overwhelmed by the judgment from other community members, including her husband.

Dr. Horton ensured the patient that there could be other contributing factors and that she should not feel any shame. Dr. Horton then continued to educate the patient on her sexual and reproductive health and provided referrals to a local fertility clinic, hoping that the patient would be confident and in control of her own health. I saw a moment of relief in the patient as she was given this guidance and support that she could not find in her loved ones. Overall, it was a humbling and inspiring experience to see Dr. Horton address each patient’s concerns with empathy, provide educational information, and empower these women to have autonomy over their bodies. I hope that our patients felt comfortable and safe sharing their stories with us, and that we were able to provide some kind of reassurance.