el campo

We met back up in the afternoon to head back to Cuenca.
J2 and I were working with Dr. C in the morning, driving out to el campo, the countryside. We didn't know what we were doing or where exactly we were going, but after some difficulty finding 1-55, Dr. C picked us up and we headed out to Health Area #3 to meet the students he was supervising there in their rural rounds.
We checked in with the nurse in the health center and then headed out to a local elementary school to meet them. They were just arriving, two fourth years, and we walked with them out to the playground to be introduced to the elementary students who met there.
The whole school was assembled there, the children in red shirts and blue skirts and pants, and were lined up to sing the national anthem. It was a slightly surreal experience, with speakers hanging from a pole along the side of a flat dirt soccer field, the school bathroom in the far corner across the grounds, mountains crowding the background in the morning sun, the anthem crackling across the anachronistic speakers whose sound and appearance were reminiscent of a MASH episode. We were introduced: the doctor - a family physician from the outskirts of Cuenca who had been working in rural health centers and Cuencan clinics for 30 years - and the students, including us, the visitors who would be assisting in their screening physicals.
Today we had the five and six year-old boys for basic health screens of HEENT, heart, lungs, hernias and phimosis. Most of the exams were benign. Of twenty boys we found one case of phimosis, a bifid uvula and a heart murmur. Lots of boys didn't have underwear, and a few smelled of urine so we talked about this, discussing hygeine that would be brought up with the parents.
Interestingly, the unusual cases were brought to the teacher, who would facilitate the discussion with the parents.
It was raining heavily the next morning on our way to The University of Cuenca for a mobile surgery day, but upon our arrival we learned that Dr. V, the anesthesiologist, was ill, and the surgeries had been postponed.
We had enough time to make it over to VCM hospital to make the most of our day.

Ice cream highlighted evening plans. Mixx was the bomb, a coldstone kind of place that made their own product, including highlights like cerveza, sangria, tequila, and whiskey flavors. It was staffed by locals and one Canadian who seemed to always be there when we visited, giving us some extra attention that was appreciated. I never tipped ice cream servers before, but it was worth it. Plus there were three parlors in the San Blas center that was only a few blocks from our house.

The next day we were back out with Dr. C. This time we were making house calls.

morning milk and saddle

It was wet and we had a lot of walking to do. We met a recent University of Cuenca graduate who was training two students. Dr. C stopped everybody we passed on our path for a quick physical and update. The point is to identify conditions that needed attention when the local clinic was staffed or encounter those who are unable to make it to the clinic and require attention at their home.

This woman could barely see or hear. She was somewhere around 90, and was resting after binding these crops.

We visited a hat shop famous for Panama hats, which are made in Ecuador, but made famous by Teddy R who wore one to the building of the canal.

They cut and steam press the hats to order.

And the rain began again in earnest.

south cuenca from rooftop near the center

Vilcabamba

Another bus ride. This one was supposed to be much shorter but it was still close to 5 hours for the first leg to Loja and less than an hour for the second up to the remote mountain town of Vilcabamba. It is the most common form of transportation here, as in Colombia, and isn't without problems. You cannot believe the estimated length of the trip. The bathrooms in the rear are horribly gross, if present, and difficult to use -even for a guy- on the winding roads. The direct bus will make as many stops as they want, filling seats and stopping for any stop requested, so you can get on and off at any point along the route. It can get very crowded - people doubled up in seats and standing. You will see random hook-ups, crying children, leaking windows, eating, vomiting, snoring and maybe even five hours of sylvester stallone movies. You will not see air conditioning. The buses here were overall in better shape than in Colombia. To begin my first Colombian bus ride in Cali at midnight a roach crawled across my arm. It was not a pleasant introduction.
The buses are convenient, inexpensive, regular and the prices are standard=no haggling or tourist tarriffs.
This ride was the disco bus. I recognized some of the songs, but many were in English and I don't remember hearing them before. They sounded like chinese remakes of american disco and it was horrifying and funny. And they played in a convenient loop that allowed us to enjoy them several times. My neighbor was in a hurry and kept checking his phone and cursing. He got off early and was replaced by an elderly campesina, in uniform of dark solid skirt and colored sweater, but with a black hat rather than the white ones more common in Cuenca. I never discovered the significance of this gang attire.
The second bus to Vilcabamba was mostly school aged kids returning home for the weekend. The interior running lights in the bus were rings of neon blue and orange fixed below the carry on rack. It looked like a disco bus and the effect through the hills, twists and curves is somewhat nauseating.
Vilcabamba is a small and fairly common mountain farming town, known for its spring water - rumored to posses anti-aging properties - and for a variety of outdoor activities. We got in at 10pm and it appeared completely silent. J2 had looked up a hostal and we grabbed a cab to carry us the 2km up the hill. We walked down a lush corridor of flowering foliage quite amazed by the neat beauty of our surroundings, even in the dark. The front desk was closed and I was grumbling already because we hadn't eaten, but we found the bar open and the bartender located the proprietor and made us a scratch pizza! We got the last room available.

This was the view in the morning from our room:

I jogged down to the city center.

Our view from the cafe, which had an amazing fresh fruit, bread, real coffee, meat and eggs or crepes made to order included:

 They were booked for the next night, but our gracious German hosts welcomed us to stay for the day and see if anything opened up. We packed up and put our things behind the desk to head out for a hike.
Our hostal created a map system of nearby trails, so it was fairly easy, with some guidance from the locals, to find the trail and the maps served well thereafter.

 

we kept seeing these huge spiders

One of my few shirts on this trip was a Christmas present that says Lone Star State, which led to a conversation with a couple that we met who then hiked with us for the day.

After the hike we headed back for some German food and I went for a swim while the girls got ready for a massage at the spa.

 

Hostal cafe with Mandango Mt in the background

We moved into the city center and I found a band playing there that I listened to for hours. It was in a corner cafe that was half full of musicians and they kept rotating members in and out of the audience and band, changing up styles and players with a mix of traditional Quechan and Spanish music.
The next day the girls were going horseback riding, but I wanted to hike Mandango.

It was palm sunday though, so I stopped at church.

This trail was really hard to find, so if our dorm-mate hadn't given me a good description I would have gotten lost. You start by walking up a dirt road by a cornfield, then cross a part of the field, under a barbed wire fence, through some brush where there is no trail at all, then onto a well marked cow path that has overhang at four feet so you walk bent over for a wandering twenty minutes before coming to the trail proper.

trail beginning

first peak

destination - second peak

second peak view, first peak in background

Quirofano Movil

Thursday was our first mobile surgery experience, and with Dr. R out of town it was predicted to be busy.
We had 9 cases scheduled, and although none were complicated, it would be a full day.
The area we were visiting was a common health center located less than an hour outside of Cuenca, in a pueblo called Quingeo. It was part of Health Area #3, a common location for Cinterandes family practice docs and medical students to follow patients in, given its proximity to the city.
We met at the Foundation office and piled into Isuzu-Chevys with Cinterandes logos that sped up winding roads from the city into the surrounding hills, leaving the pavement and bouncing over packed dirt caminos, passing campesinos in their white hats hauling bundles of sticks, wares, and babies, tending cattle, and washing clothes. Women in traditional garb weilding scythes mowed grass and weeds that were later bundled, dried and burned.

Staff members were well ahead of us, readying the truck and pre-oping the patients who were waiting in the health center to be called. Family members were waiting with them, highlighting the advantage that this unit has over the hospital setting which places many barriers between the patient and the process.

Patients changed into a gown and were called into the truck for booties and hats. Behind where the patient is seated in this photo are the parts of the truck outfitted to support the OR that is housed in the rear of the truck. There is a small bathroom/changing room/scrub closet, a dual well sink for cleaning and sanitizing instruments and scrubbing, floor to ceiling shelving that holds supplies ranging from surgical instruments to refreshments, and an autoclave for sterilization. One interesting visual for the day was the counter space occupied on one side by clean instruments and the other side by a waffle iron that we were using to make grilled cheese.
Once the surgery was completed, the patient's cart was rolled out the rear of the quirofano and lowered on a hydraulic ramp so they could be transferred to post-op to recover from anesthesia. Once the patient feels able they are allowed to return home. For some of the larger procedures, including lap-choles, they may stay the night with a nurse.

All of the cases are elective procedures and patients are screened very effectively to ensure good outcomes that do not require the services of a larger health facility. So, compared to a hospital, the patients are healthier in general and complications are nearly zero. Problems are identified by local health care providers - sometimes students and then verified by their attendings- and then referred to Cinterandes to confirm and perform a thorough history and physical to verify the need and suitability of each surgical candidate.
Our cases were mostly minor skin lesion removals, with some larger and more complicated masses, as well as two more involved laparoscopic procedures.

 A surgeon who had recently completed his residency was performing most of the operations with a resident assisting most procedures and the seven of us students took turns as first assist, second assist or scrub tech.
It was a bit crowded, but everybody got a taste for it, since it was a different experience from the typical OR. Dr. V was the anesthesiologist, so was occupied in the OR nearly the entire day, while Freddy, one of the drivers, ran back and forth full time as the circulator. Dr. B worked as the scrub tech or assisted, depending where the students were, and it was obvious that this was a very capable, if skeleton, crew.
We finished late and missed Spanish class. I had my last day at VCM the next morning, and there was an emergency abdominal aortic aneurysm that kept me busy from the morning up to our afternoon planning meeting. Dr. R was back in town and had a recent birthday that we all celebrated. The next week J2 and I would be heading out into el campo with another doc to see how that program worked, a mobile surgery day was scheduled on University of Cuenca's campus on Tuesday and Thursday was post-op follow up leading into a holiday weekend.
With the celebration, our meeting ran late, so by the time we got home M and J2 were planning to head to a small southern mountain town for the weekend, and at the last minute I joined them.

la segunda semana

The beach is great. I love the water.
As we walked around town trying to pick someplace to eat, which is difficult with 6 people, we developed a strategy to overcome unassertive group tendencies: we would pick one person to make all decisions. This works quite well. Except when you pick somebody only interested in ice cream to find a dinner place for everybody else wanting a meal. Then it's difficult again. But we managed well, got our dinner, and ended the night with a friendly game of spoons.
It's a card game.
I think I was already beyond the plural of 'spoon' when we gave up, but it was a great day.

And my back felt well enough to start jogging again.
Shoes can occupy half of my backpack, so if I bring them, I feel obligated to use them, which is good. So after we got situated, I read some and went to bed.
The next day was more of the same.
After a jog, we were on the beach. I spent nearly the entire day in the water, unlike my sunbathing counterparts, but I was careful to slather sunlotion over my lumenescent body at each break, to avoid the fate I felt my comparably white companions doomed to endure.

But, by the end of the day, the water had been unkind to me, and in the close equatorian coastal sun, I was red from neck to ankle, save the short line.
Back in Cuenca, Monday marked the 454th anniversary of its Spanish colonial founding and was a holiday. We took an early bus back to enjoy some of the festivities. It turned out they didn't actually take place until Tuesday, but it would be an early day at a new hospital, so I would have a nice night of sleep in the mancave- the affectionate name of my back apartment where I stayed separate from the Sonias, the FL girls, and J2, a girl from WA who was just starting, all staying on the second floor of the main house.

VCM was a lot different from Del Rio. The largest public hospital for the city of 300,000, most of the patients were uninsured and could pay very little. Their affiliation was with the University of Cuenca which is three times the size of U of Azuay and it was difficult to track somebody down to work with. Most of the time was independent, although if I found a resident early enough I could scrub a case as the tech, which is something not done in the US.
After the OR, the ER had a surgical area where the interns performed procedures in the afternoons, which is good suture practice and some difficult Spanish. A lot of the practices here made me think of a poor public hospital in the US maybe 20 years ago. Or more. Sutures, sponges, saline - all were used very sparingly. Gowns were reusable after sterilization and instruments that weren't used were retained. The halls were hauntingly crowded with people waiting. Rooms had no curtains or dividers so patients were four to six in a room appearing like a dorm. There was very little equipment in the rooms, and most what did exist appeared very old. Paint peeled from the ceilings. Patients were transferred from hospital to OR cart by changing beds over a four foot wall. It was difficult to obtain supplies, like gowns, gloves, boots, masks, suture kits - and some of these required an order. But it was busy, there were a lot of cases, and I met some helpful residents and attendings.
Tuesday night after class I saw giant firework towers assembled in front of la catedral vieja and so the three of us from 1-55 went out to see the celebration. It was J1's birthday the next day too, which made it even more fun.

T

These candy apples are awesome. There's a piece of bubblegum at the bottom so that you can work the candy out of your teeth!
I kept seeing these cones on piles of ice-creamy stuff on carts around town and wondered how it didn't melt. It is some type of flavored foam, almost like marshmallow, almost like meringue, but less tasty than either.

The next night we went to a restaurant on the far south of town on the side of Turi mountain. We all met there, and as most places in the city there is no address, just the name of the restaurant and the abutting mountain, which makes for interesting navigating. It is on the fourth floor of a complex housing a spa and gym, so I was a little surprised cabbies did not know it, and many of the students recommended it as a classy, healthy and reasonably priced hip place.

It had great views of the city, too.

 

a la playa

To get to Montanita you have to connect with a bus in Guayaquil. B, one of the OSU girls, spent a semester in Cuenca and knew a company with a private bus-ette that would shave an hour and a half off the drive down, avoiding a lengthy repeat of my ride in. Word was that they were safer as well, though the rubber we left on the curves, and the balding shoulders of the tires noted at our gas stop, left me unsure of how they gained this reputation.
Turn after luscious green turn we worked our way up from the 8,100 ft of Cuenca, passing Cajas National Reserve Park's waterfalls with bucolic pueblitos scattered throughout, and descended into the cloud cover shrouding former colonial outposts marked by steepled churches, bell and clock towers and surrounded by crude brick and mortar with makeshift corrogated tin roofed structures before arriving at flats and banana plantations that inundated the outskirts of the port town of Guayaquil.
We had a two hour wait for the public bus there before leaving the rolling hills behind and arriving at the small, touristy beach town as the sun made its way to a high mid-horizon perch.
Traveling with five girls is funny. With five female-soon-to-be-physicians is hilarious. There is a lot of planning, discussion of possible plans, meal planning, bathroom planning, safety planning, sunscreen, reservation and budget planning.
These are probably good influences on me.
Plus, I didn't have to do much. And it makes sense: for instance, the bathrooms often don't have toilet paper, which is pretty inconvenient if you're not carrying any.
We had a reservation at a very nice beachfront hotel in a six bed dorm room. I changed quickly and hit the beach. The water was refreshingly warm and the waves were breaking regularly in 4-6 foot swells,  making for perfect body surfing. I was lost for hours.

Afterward there was time for some extra leg.