Doctors Without Borders

It was a Tuesday the first time we officially met as co-workers. Dayna had just arrived from living on the Ecuadorian coast, and would be departing as soon as the March medical work was complete. Lauren had arrived from her home in Hawaii and was to be employed by Tandana for the following 7 months. I decided to volunteer as an “employee” on a full-time basis for the month. And of course, Anna was the boss.

We had exactly 4 days to plan and organize and learn to work as a team before the first doctors and volunteers arrived on Saturday. Time was tight and there was plenty to be done. We were each designated a role, although with a staff of 4, things remained more flexible than not. Having a background in medicine, I decided to act as the pharmacist for the tenure of the clinical work. Dayna was logistics and accounting, and Lauren became the community-volunteer-doctor liaison due to her superior Spanish.

We needed to have an accurate inventory, both of medical supplies and medications, prior to the start of clinics. More than 300 drugs and 15,000 pills, all with several brand names in both English and Spanish, made the task more Herculean than we expected. The job was complicated by the fact that we had more drugs and supplies arriving with each volunteer and doc. Needless to say we spent 14-16 hour days counting pills, gauze pads, and syringes until the very last moment on Sunday night.

According to Anna, Day 1 is always pretty rough. The staff still doesn’t know exactly what to expect or what to do. The volunteers are still acclimatizing to the altitude, culture, and everything else that goes along with operating a mobile clinic in a rural village in the developing world.

To provide a little background, Tandana started to provide free medical care to communities outside of Otavalo about 5 years ago. The same two providers have come from Montana every year, once in March and once in September.

Everything else that a clinic needs to survive, all the way from check-in to vitals to pharmacy, is run by volunteers who may or may not have any medical background or training. The staff is responsible for training, filling the gaps, and making sure the volunteers enjoy themselves while ensuring that patients are being properly treated.

It is sort of like summer camp meets hospital…sometimes minus the most basic of needs like electricity and running water.

The communities we visited varied in every conceivable fashion, from distance to the nearest city to population to degree of competence and organization. The common variable was lack of access to health care for various reasons. People sometimes arrived on horseback from villages far away.

For the first two weeks, the format was:

6:00 AM – Wake-Up
6:15 AM – Breakfast with my Family
6:40 AM – Walk the 50 minutes to Las Palmeras (our center of operations)
7:45 AM – Eat Second Breakfast with Volunteers and Staff
8:15 AM – Load the Truck with Supplies and Pharmacy

9:00 AM – Arrive in Community and Set-Up
9:15-1:30 – See Patients

2:00 PM – Lunch (varied locations, sometimes in the communities which was always interesting, other times at local restaurants or the hotel)

3:00 PM – Afternoon Activity (included everything from a hike up a waterfall to a visit to the workshop of a traditional weaver)
6:30 PM – Spanish or Kichwa Classes (taught by myself, Anna, or Lauren)
7:00 PM – Dinner at Las Palmeras
8:00 PM – Debrief with Volunteers (talk about the day, what happened, what could be better, strange patient cases, etc.)
8:30-9:45 – Prepare the Pharmacy and Supplies for the Following Day
10:15 PM – Get Home and Go Straight to Bed

The volunteers ranged from a couple of 19 year old pre-med students from Washington to a 50 year-old nursing student from Canada to a 35 year old physical therapist from California to a 75 year old bilingual grandmother from Ohio, and everything in between. The group dynamics were always fun and challenging but overall we ended up with some great people with a real passion for travel and adventure.

Even 20 minutes free for myself and my co-workers was a blessing. The work was fun but definitely draining.

Luckily my host family was understanding of the time I was putting in and we took advantage of catching up every 30 minutes in the morning we had for breakfast.
The clinics themselves were only clinics in name. Typically we set up shop in the local school; it being the only building in the villages big enough to allow us to do our work. On one occasion, we worked out of an old woman’s house and several times, we simply worked outdoors. We did our best to provide each doc with at least a semblance of privacy (often just a blanket held up by a volunteer for a pelvic exam).

Intake and vitals were taken outside. Pharmacy and tests (we did pregnancy tests, H. Pylori tests, and strep) were typically given a room, although sometimes just a hallway, a bench, or a corner, and once in the back of the truck itself.

Sadly, we sometimes turned patients away for lack of time and resources. Luckily this was not a common occurrence and we did our best to triage and be sure that everyone who truly needed help was seen.

Translators were an essential part of our work. This didn’t just mean Spanish to English, but often times Kichwa to Spanish to English. Being in such rural areas, a good number of residents spoke only Kichwa. Just as important were locals who assisted in translating local and cultural customs. Medicine receives an entirely new twist when assumptions about patient behavior learned in the West can be thrown out the window.

A couple of funny examples:

A woman was having eye problems and the doctor recognized the need for a simple saline solution. As often happened, the pharmacy we carried around didn’t have any eye drops. No problem, thought the doctor. I’ll just have the patient mix salt and water and apply it to the eyes as needed. Unfortunately things were not made explicitly clear. The patient visited a local doctor we work with several weeks later complaining that she had put salt in her eyes and it stung like hell! She said putting the water in after didn’t make a bit of difference.

As with many patients we saw, a woman saw one of our docs with a whole host of medical complaints. The doctor took them one by one and dealt with each as he saw fit. At the end of the consult, the woman left with several prescriptions looking relieved. I ran into the woman on the street two days later. She said “Aren’t you one of those doctors?” I knew what she meant and asked her what the problem was. She replied, “Well I have a problem with dryness on my legs and feet and the doctor gave me some cream.” “Go on,” I said. “I just don’t think the cream is working because when I put it on, it sort of burns and then gives my legs a fresh feeling…” “Can I please see the cream?” I asked. She ran into her house and brought me back the tube. It said in bold red and blue lettering “CREST.” She, like many patients, was given toothpaste and a toothbrush when she left the clinic. Something had been lost in translation and there was no moisturizing cream prescribed but she presumed that’s what the tube of CREST was for!

Luckily no harm was done and we all got a good laugh, including the lady with minty fresh legs! Some patients had much more serious problems and much sadder stories to along with them. Realizing the limitations of a clinical operation such as Tandana was a struggle. Sometimes there really was nothing that could be done. Other times, patients were referred to the hospital for more tests, surgeries and follow-up. One sad example:

There was a 12 year old boy who came in complaining of a headache. After talking with the doctor, it was discovered that he was suffering from stress and depression. Imagine a 6th grader with those problems. He finally explained that his father had just been killed unexpectedly and he was now the man of the house and responsible for his family of 6....

The logistics of follow-up are more than half the battle in places like these. Patients often live hours away from the nearest city with no transportation and little money. Although I will be writing more about this in a later blog, myself and Lauren are doing patient follow-up and transporting patients in the coming weeks and months.

After three weeks of little sleep, lots of work and accompanying emotions, the four of us were ready for a break. Unfortunately, there was one week to go and it was supposed to be harder and longer the ones before. Each year for the past several years, a group of med students and doctors from the University of Utah come down for a week of clinics with Tandana. They come to work and get experience, which means when we go out to communities, we stay until no more patients remain, regardless of how long that might be.

For another blog…

Love
Kent MD