The gray pickup truck rattled along the rocky path, careening back and forth on a steep incline that reached for the snow-capped peak masked by clouds. While tires slid and kicked up trails of dust that diffused into the mist surrounding us, I was still able to catch a glimpse of Chimborazo, a volcanic pyramid of Ecuador, through pockets of clarity in that atmosphere. Soaring at breathtaking elevations of over 20 thousand feet, Chimborazo is a point near the equator where one can be closest to the sun while standing on Earth.
Upon reaching a small plateau somewhere closer to the top, my guide, Galo, helped me suit up with elbow pads, knee pads, a helmet and hat, radio and other protective gear to wear over the four layers of clothing I had come prepared wearing. I looked up into the deafening silence of clouds rolling lifelessly like tumbleweeds across a primordial landscape flattened underneath the might of a glacial throne. Then I pushed the bicycle off and started my way down.
The long and rutted way down stretched out before me through a chilly and otherworldly landscape of lunar gray and dull tan colors, dotted with small shrubs and the occasional pack of wild vicuñas, animals closely related to the llama. I continued downhill on the muddy trail as dusk quickly approached and found myself amidst tiny concrete structures and huts, the houses of rural villages. The homes sat scattered apart from one another along the dirt trail, some windowless and others with crude metal roofs.
On more than one occasion, I was forced to stop for the animals blocking the trail, whether they were cows and sheep roving along to some new undiscovered plots of grass, or llamas staring with curiosity at me, the alien in their habitat. However, the most memorable aspects to this developing scenery were the local inhabitants. In particular, I saw the children of the villages here and there, many appearing to be no older than six or seven years of age. They would come out from the grass nearby or from chasing their wandering livestock to watch, sometimes trying to run alongside the foreigner on a bicycle zooming by and then, just as quickly, disappearing into the evening redness of the horizon.
Fresh in my mind throughout this mountain biking endeavor were the previous two weeks, which I had spent working in the pediatrics ward of a general hospital in Riobamba, Ecuador as part of a medical Spanish immersion program. I thought of the children I interacted with there, the doctors I observed, the differences in culture I questioned, the Spanish I gradually improved, and the continuing discoveries I made regarding the spectrum in which medical care is provided across the globe.
At the risk of oversimplification, the hospital floor where I worked was comparable to a time capsule notion I have of the 1960s or 1970s American hospital, which I admit I have only encountered in films. One would find that the rooms had multiple beds — all rudimentary — occasionally paint-chipped metal frames bereft of electronic position adjustments, and often fully occupied. Nurses, without exception, were dressed in starched uniforms, donning old-fashioned nursing caps on their heads, with male nurses even more noticeably absent than I had reasonably expected. Paper records and forms stood in place of computers and technology. The extent of morning rounding followed by afternoon outpatient work by the same physician demonstrated to me that hospitalists were much less commonplace. Telling above all, however, was the primacy and final authority of the physician in health management, which was in rather glaring opposition to much of the patient-centered care that we, in the United States, are taught in medical education.
It is rarely, if ever appropriate, to point to one single factor in any analysis because there are more often many forces at play. Indeed, many features of what I call this “time capsule” comparison are the result of several factors: Ecuador’s economic development, South American cultural differences, my observing a general hospital as opposed to a private insurance facility, the particular region in which the hospital was located, and the fact that it served a wide area of patients, most of whom were indigenous. Despite all I saw in Ecuador, clearly there was much more I had not witnessed or experienced during my limited stay. Nevertheless, the differences stuck out strong to my foreign eyes, whether it was the manner in which iodine was poured over surgical appliances prior to quick procedures, the general weathered appearance of the blue tiles of the ward’s hallway dotted with pealing images of cartoon characters, or the traditional, colorful and hand-sewn indigenous clothing that so many of the patient’s parents and families wore.
The three most common conditions I saw affecting the children were pneumonia, malnourishment and automobile accident traumas. Pneumonia presented so routinely that patients with infections, no matter how young, were usually the ones in and out the quickest. Malnourishment revealed itself in such cases as a four-month-old boy with kwashiorkor and an indigenous baby with cleft lip whose weight contraindicated surgical repair. We witnessed a significant amount of motor vehicle accident traumas, too. I witnessed two young boys, terrified inside the hospital, suffering from fractures of the humerus as a result of being hit by a car. The worst trauma victim I saw had temporal-parietal fractures, face lesions and secondary left leg immobility which left him initially unable to walk. I still remember the raw panic in the boy’s face when he was unable to comply with the doctor’s order to raise his leg.
There was a baby with hyperbilirubinemia who was placed under UV light as part of treatment. There was a little girl who had suffered maltreatment and abuse from her mother, whom all of the nurses on the floor promptly seemed to shun. We saw a young boy with tangible hepatomegaly and Hodgkin’s lymphoma, multiple patients with HIV infections, a boy with hernia and sepsis, and so forth, some more routine and others more serious. Many of these conditions I was expecting to see at some point back home, while others I now do not know if I will ever see again.
As rewarding as the pediatrics experience was, I also believe that the differences in hospital culture became most apparent within the pediatric setting. For example, during rounds, all visitors, including parents, were required to step-out of the room, an uncomfortable separation for both the parents and their children, who promptly began screaming. Furthermore, I had difficulty understanding what might have been considered normal behavior for medical professionals interacting in the presence of patients. Some personnel seemed more interested in having fun, even making inappropriate jokes in front of their patients, instead of actually talking to and comforting the visibly lonely and frightened children.
Consequently, we did do just that and began talking to the children so that we could not only practice our Spanish, but to hopefully make an inherently frightening setting a little less intense. We also were curious to hear what they thought of the hospital in their own words. Our first attempt was met with confused and guarded expressions, as if the children were wondering why they were being approached by yet another white coat. One of these children was the frightened young boy with a fractured humerus who had arrived at the hospital after being hit by a car. Within just a short span of time, I can recall entering his room to find him sitting up, smiling and waving to me whenever I walked towards the often empty chair next to his bed. I always had the impression, even upon leaving, that some of the residents-in-training at the hospital found the foreigners’ patient conversations odd, but frankly I began to not care about that.
In fairness, however, we also observed many heartwarming episodes and recoveries, sincere care and concern demonstrated by the physicians we looked up to, and even the simple, inherent goofiness of doctors and staff playing and interacting with the kids. The boy who had presented with temporal-parietal fractures, panicking because of the earlier condition involving his leg, gradually regained his ability to walk. Over the span of many mornings on rounds, the child, perhaps four feet tall, surrounded by a sea of white coats towering over him, initially stumbling back and forth between his bed and the door, gradually was able to walk the distance as if it were completely normal; the terrible swelling in his eye reduced, and the red lesions across his face quickly began to heal by the time I had left. It was difficult to not be moved by that sight.
The pediatrician I shadowed during external consult genuinely enjoyed his work and cared about his patients. He established a routine that consisted of fist bumps rather than shaking hands. It was evident that instead of treating his patients as checkboxes, this physician showed interest in more than just the child’s physical health. He was well-informed and invested in advocacy. In particular, he highlighted the importance of improved instruction and regulation in driving customs in order to prevent the accidents. He emphasized improved sexual education in schools as a means to remedy the division of gender-related conditions that we had also seen in patients. Finally, he called for improved education in nutrition and cooking to prevent the kinds of malnourishment present in poorer rural populations that resulted not so much from the lack of food, but rather from the cultural methods of food preparation.
All of this was on my mind on that last day before leaving Riobamba as I saw the children alongside that dirt trail in the countryside around Chimborazo. In particular, I thought about a little girl who presented to the pediatrician’s office only a few days before with a significant heart murmur, a tangible foreboding of what possibly lay ahead. She was of the indigenous population from a rural area. The girl would have to be taken all the way to the capital, Quito, for an echocardiogram to determine her diagnosis as the test was not available for children at the Riobamba hospital. For many of us living comfortably in the developed world or even for those of us with significant struggles, it is difficult to fully appreciate just what something like this meant for these people. The capital was three to four hours away, not to mention the difficulty involved in actually traveling to the hospital for a family with no car. The child would then have to receive the procedure after sitting among the long lines of people in crowded hallways we had seen waiting for an appointment every day for the past two weeks. Uncertain still were the results and implications of the echocardiogram and the number of days this family of very modest means would have to spend in the capital far from home. The child sat there following her examination, calm and at ease with a slight smile and large dark eyes that were unable to see her path ahead. The mother, despite discerning more clearly the inherent implications, also smiled upon looking at her daughter’s face. Upon their leaving, the pediatrician shook his head, as if in disappointment that there was nothing else to be done and little else he could say, a feeling far too familiar.
While I may never know what happened to that family, I could not help but think about them and the other patients we had seen, so many of whom had come from the very conditions I found myself unexpectedly witnessing firsthand on the bike trail that stretched out ahead. It made me wonder which of these children, there running alongside llamas and sheep, would have to travel the two hours to the nearest hospital in Riobamba under similar circumstances or which will be unable to acquire the care they needed and deserved. While the hospital experience shed light on our collective shortcomings, it too highlighted the immeasurable impact of individuals devoted to their specialties and the resilience of people willing to sacrifice in ways unimaginable in spite of the odds against them.
Near the snow-capped upper heights of Chimborazo, I was unable to glimpse the summit, and even upon descending, I never was able to see the mountain in its entirety. However, I found myself pleasantly surprised by what I discovered during the descent: the views and sights of the locals in the villages I could not see from either the upper heights of mighty Chimborazo, nor from within the hospital in Riobamba. I never could have anticipated holding the images of that day so vividly in my memory even up to now. The bike trip served to put in perspective for me a journey far larger, an apt reminder of what our focus, motivation and attitude should be along the path we choose in medicine.
And besides, the view of the mountain from the bottom looked better than from the top anyway.
&Medicine delves into the applications of medicine in other disciplines: public health, pharmaceuticals, business, law, art, politics, food, history, philosophy, any pursuit outside of medicine. It is a collection of medical student work that bridges the gap between medicine and the world around us.
Contributing Writer
Children's Minnesota
Brian Lefchak graduated summa cum laude in biology from Drexel University in Philadelphia and from the MD/MPH program at Drexel University College of Medicine. He completed pediatric residency at NewYork-Presbyterian Weill Cornell Medical Center and is currently a fellow in pediatric emergency medicine at Children's Minnesota. In addition to a career interest in bioinformatics, he is a lifelong musician and performer with hobbies including photography, history, foreign travels and soccer.
The views and opinions expressed in these articles are those of the author alone and do not necessarily reflect the position of associated organizations.