Managed Chaos

The pharmacy students always choose the back of the bus!

Our first full day of work-- no anxiety today after seeing about 40 patients yesterday. We felt prepared. Our schedule is set for the rest of the week: breakfast at 7:30, leave in the Camp Hope van for the church north of Quito at 8:30; start seeing patients at 9. I did point out to the team today that we are being driven driven back and forth in the short bus, as they wondered why people stared at us all along the route. Our journey begins on our narrow street, and we quickly merge into a wide, crowded boulevard lined with luxury shops selling the latest Paris fashions-- the dresses in the window were all red today instead of yesterday's blue. At most intersections, indigenous woman in bowler hats and blankets sell vivid oranges in long narrow nets-- maybe 10 oranges to each bag. These woman look very tired and defeated by life. I wonder how many orange ribbons they sell every day-- enough to eat? I wish I could take a picture of them but it seems almost exploitative to do so.

 As we drive north through Quito on the Pan American highway, the crowded city street begin to open up to expansive views of the highlands that line Quito on both sides. At first, the hillsides are all houses, every tree stripped away and every inch of earth covered in cement houses--a never ending maze. I wonder how wide the streets are on these hillsides, as it doesn't appear that there is any space at all between the buildings. As the cement fields finally end, the terraced fields take over the hillsides with dense forests above and below. In the morning the sky is bright blue and the clouds high and white. Sunshine reflects warmth and the air feels perfect. On the way back, the clouds have darkened to a dull grey and settled down onto the mountain tops and wisps tease the valleys. There is usually an intense but brief rain-- on Sunday we were treated to a violent thunderstorm. And then it ends. The clouds stay low and the air cooler, but the blue rejoins the sky.

Dr. Shariat and Thanh Nguyen interview a patient

Dr. Wilcox exams a patient while his mom looks on

 Thirty or so patients are sitting in a small room upon our arrival. Some smile and wave and greet us with holas. Others clearly aren't sure what to do as we wind among the chairs carrying duffels and boxes, returning greeting. Two little boys in the front row are anxious to show off their English and say "hello, how are you?". I reply in my finest English. We have no nurse today to assign a # to patients and take vitals. A volunteer is trying but she has no stethoscope, so I run up to dig out the extra.


The delay is welcome as it gives the pharmacy students and residents time to set up and get organized. I am summoned back down stairs-- the volunteer is unable to get a small boy's blood pressure-- the cuff is for adults and won't work for children. I inquire as to who this boy belongs to. I'm told he is "special" and he is here alone. He is a little limp and doesn't tell us his name. Now imagine if you will-- a small room with about 30 people sitting very politely and quietly in chairs with more arriving by the minute, a volunteer who isn't really sure how to check people in, pharmacists rapidly sorting and shelving meds, doctors waiting to see patients, of which none are ready, church volunteers speaking rapid Spanish to an English-only speaker (me) while I am simultaneously trying to get at least three patents ready to be seen, running up and down the stairs delivering requested supplies and trying to figure out how much to worry about this mute little boy. I take him by the hand and lead him up the stairs-- he has a hard time. I find a translator who tells me his name is George. We start calling him George. A few minutes later, he finally speaks and tells us his name is actually Edison. Progress. The rest of the story was pieced together from multiple sources. He was at the church for breakfast and had a seizure ("crisis"-- took me a bit to figure that out). He was post ictal when I first met him-- not "special". I asked one of the residents, Carrie Wilcox, to take him as her first patient.

When I next checked in with Edison, his mother was there with a baby in a blanket papoose on her back and an older sister at her side. Her face was full of concern and worry. Edison has had seizures since he was hit in the head at age 4-- he is now 10. Dr. Wilcox was working with the social worker and the mother-- Edison does take seizure meds but he has been having more and more. We decide it's worth getting a blood level-- figuring out how to write an order for one blood test took 30 minutes and three translators. The mother leaves.

By this time there are probably 50 people upstairs in a relatively small space, kids are running everywhere, the vitals are becoming rare, no one is selected by their #, but rather by who knows the church volunteers, and we have made almost no headway. It really was (mostly) managed chaos. Just as we started to make headway, we were told that it was time to stop and eat. It was only 11am, so as we were shooed out of our rooms we stared bewildered-- lunch isn't until 1 pm. I'm told the pastor wants us to stop and take a break and we find the table set with Doritos and watermelon. My American culture brain cries out "are you crazy? We have patients literally holding up walls for lack of space, we can't stop now!!" but we all sit gratefully and eat Doritos and watermelon and savor the pastor's favorite juice. It was very very nice. We just aren't used to taking breaks. I check in with the doctors on how many patients have been seen and suggest that we may need to speed up. Edison shows up with his mother before we get back to work. He's just had another seizure. We did what we probably should have done initially and just increase his dose-- it's really hard to give up data when that is the world we work in. Data costs money and many of the people we saw today barely make it day to day. They have no budget for data.

Calvin Culver teaches a patient how to check her blood sugar, with Martin translating

Dr. Weiland dispenses medicine from the mobile pharmacy

Amanda Steele, pharmacy student

Mimi Choate saw a woman whose blood pressure was sky high because she was out of meds--we have some emergency meds with us, but they didn't work at all. She went to the ED, because it was the only way she could get new prescriptions. Bridget Shariat, the other resident, started her day with the two boys who had greeted me in English-- their parents were worried about their foreskins and the boys (prepubertal) were worried about their penis sizes being too small--supposedly from eating too much ketchup. We solemnly (on the outside only, inside I was laughing) examined them and declared their penis' perfectly sized. I think this must be a concern that transcends culture. Dr. Shariat ended her day with a young girl who lost both eyes to cancer as a baby. She wears prosthetic eyes, which now fit poorly and were infected. I can assure you I have no experience with the care of nor the treatment of prosthetic eyes. Dr. Christy Wieland, my pharmacy counterpart, helped tremendously and we picked an antibiotic, used some of those last minute donations from the Eye center, and did the best we could. We saw 76 people today- 76 stories. Some very sad, many perplexing and we could only guess what the best course was, some happy, as whenDr. Wilcox let the 45 year old woman with 8 children know that her pregnancy test was negative after two missed periods. Everyone is so nice and grateful and wonderful to work with. Tonight we head to old town for a little touristing. Buenos nochas. No time to edit!