Settling into the Galapagos

Well, the diving didn’t work out last time, but on Monday I hit the jackpot!  Dolphins joined us on our way to Floreana, the sea was mild and welcoming, and after a very long safety discussion, we finally got wet and saw white-tipped reef sharks, hammerheads, octopus, neon orange puffers, barracuda, eels, tons of turtles, lots of colorful reef fish,  impressive (and large) coral, and much more.  The safety briefing included nothing about the sweeping current that took us out to sea, but apparently the captain was aware, because he met us where we surfaced.  My leaky regulator was also not one of the topics of discussion.  I notified the dive-master that air was whistling out of the tank behind my head.  “Todo esta bien” came the reply. 

We made a second dive in only 5 meter visibility with a strong surge.  Not as good as the first dive but again we saw sharks, turtles, fish.  Plus, it was wonderful to be able to be out on the ocean.    

My Sunday started with a sermon at a store where I stopped to buy some water.  I was heading up to Bella Vista, where I had spent two days waiting out the tsunami and part of the night watching the sick baby (who has been discharged from the hospital!).  This time I was riding my bike up for a little exercise and to see the lava tubes (2^nd largest in S. America – the largest are also here in the Galapagos but off-limits to tourists). 



Lava tubes



“God provides everything,” came the response when I asked the store owner how he had come to the Galapagos.  He had left family behind, and came out to work about 10 years ago.  He seemed lonely, and the little store wasn’t much even by Galapaguenan standards.  Turned out he just worked there; it wasn’t his store.  He only thing he seemed to have in abundance was faith.

Later that day, I got a tour of the Lava tubes with one of the daughters of the original owners of the land.  A very pleasant, thoughtful lady, she was happy and thankful to be living in the Galapagos.  I asked her why they didn’t grow anything on their finca (ranch) which was at least 2 km in one direction, as it contained at least that length of lava tube.  “Easier to do tourism,” she replied.  

We talked about the tsunami and the crisis in Japan, the middle-east, the U.S. (We had plenty of time to chat; it’s the 2^nd longest lava tube in S. America!).  “Do you believe in God?” she asked.  An unusual question in a Catholic country where most people don’t fathom atheism.   I tried to make a distinction between spirituality and religion, and was mumbling about the infamous role of the Catholic church in the Spanish conquest of the Americas when she said, “I don’t know... All this suffering and these people killing each other, it’s hard to believe that there’s anyone watching out for us.”  But then we agreed that the problems in the world were all the more reason to appreciate the peace and tranquility of the Galapagos. 

 



Santa Cruz Cactus



Last night I had to sit through some very disturbing news from the U.S. about immigration and intolerance while my Ecuadorian host family was watching.  From here it looks like we are a country full of people who have forgotten their own immigrant roots...

Construction special:

After my years in the industry I couldn’t resist.  Ecuador in general and the Galapagos specifically have some novel approaches to building.  



Great use for old tires





don't grope for this switch in the dark



Don't even ask me about screens!





a busy light-pole



This is the roof/ceiling of my kitchen. 

Yes, that’s a hole in the roof. 

Yes, those are bare wires





typical houses; the unfinished roof is
kind of like our unfinished basements



it's a great sidewalk, just watch your step!



 

random dome house




A beautiful, finished home

Some of my favorite things: uncovered manholes, spotty internet and electricity, empty taxi trucks endlessly trolling the streets (apparently gas is too cheap down here), a complete lack of personal protective equipment for workers (we had a worker hospitalized yesterday from insecticide poisoining), mixing concrete in a hole (not exactly government specs).

And speaking of construction, what we're building down here, despite all the challenges and madness, feels really good.  We are getting involved in peoples’ lives and helping them to make positive changes.  Tonight, I finished work at the hospital and headed up to the stadium, where other ICE volunteers were conducting an exercise class.  We had 25-30 people, walking, running, stretching.  We wrapped up with the sun setting on us while we played frisbee, laughing and making new friends.  Many of them we will see tomorrow in our clinic, and counsel them about nutrition, weight loss, perhaps other health concerns.  Hopefully ICE will continue to evolve with the community and help to transform lives. 

Week two in Galapagos

Puerto Ayora

In these islands, time passes smoothly and quickly like a tepid, sweaty cerveza.  This week in summary:



Saturday Market, where we do
diabetes and hypertension
screening



In our clinic, we had a slight issue with our diabetes strips, which were putting a majority of patients in the pre-diabetic range.  It seems that the tests are running about 5-10% higher than previous clinic sessions, and than the hospital.  I wasn’t worried because we were looking at other health factors, such as weight, blood-pressure, heart-rate, risk-factors (such as previous heart-attack, family history), etc., and we’ve got some very unhealthy people here.  No matter if a person was pre-diabetic or high-normal, we were recommending diet changes, more exercise, etc.  In the U.S., we use a different test  (glycosylated hemoglobin) to diagnose diabetes and to help evaluate long term (i.e. over several months) control.  However, here we have diabetics on medication who don’t even own glucose monitors!  Once a week in our clinic might be their only opportunity to check their sugars. 

The problem, according to Emily, the director of ICE Galapagos, is that people might lose confidence in our medical acumen if our meters are not accurate.  I double-checked the relevant literature and asked a diabetes expert at Montefiore Hospital in the Bronx, Ann Levine, what she thought might be the problem.  She said that glucose meters are only required to be accurate within 15%, and can never be used to diagnose diabetes.  So, we’ve changed our marketing plan to explain things a little better to inform the patients, but we’re continuing with our clinic as before. 

Encouragingly, we’ve had 3-4 repeat patients in the short 2 weeks I’ve been here who have lowered their blood-sugars, their blood-pressure, and/or their weight, ostensibly only by following the nutrition and exercise advise that Emily and her team of volunteers have amassed and that we provide to the patients in what we hope are culturally-sensitive layman’s terms.  This is why I’m going into family medicine;  I want to keep people out of the hospital and enable them to improve their quality of life – when it works it is very rewarding.

Speaking of quality of life, we have had lots of referrals to the psychologist in our clinic.  There are apparently many problems with domestic violence and alcohol abuse here in Puerto Ayora, and very few resources available to combat these problems.   Our psychologist, a Brazilian volunteer, was recently sent home for 3 weeks because the government will not grant her a visa extension.   God forbid that a healthcare professional providing much needed care in an underserved area while spending her own money like any other tourist for lodging, food, tours, etc., is allowed to stay in the country without hassle.  The word down here for that kind of thoughtless red-tape is “ burrocracia” (with extra emphasis on “burro”).

In an earlier update, I mentioned a study I would be conducting to fulfill my medical-school requirements for graduation.  Because I knew my job here in Galapagos would be mainly health and nutrition education, I wanted to show that when people learn about health, their health improves.  Of course, the foundation I have been working for, ICE, is also interested in seeing the results of their efforts, and the volunteers and Emily have been collecting data over several years about health and health education.  It’s wonderful to have so much data, and I am going to try and dovetail my study into the existing research to maintain the continuity and integrity of all this great information.  For me, it means a passing grade, but for ICE and the people of the Galapagos, proving that education and prevention are improving peoples’ health could mean more government investment in this and similar programs.   

I am hopeful  that some of my colleagues in medical school at Albert Einstein in New York will be able to come to the Galapagos and continue this type of research and promotion of primary/preventive healthcare and to continue the study.  It would be wonderful to follow these patients for decades and help to keep them healthy!

You’ll be glad to hear that the baby with pneumonia is doing better.  Still in the hospital as of this writing, but maybe able to go home in the coming week.  At least the baby was able to receive antibiotics here, if not many of the other tests and monitoring that would have been available in Guayaquil.  I still fear that the child may suffer some sequelae, neurological, cardiac, pulmonary or otherwise, but that’s another story for another blog. 

On a purely personal note, Carolyn (my recently betrothed ) and I found out on St. Patty’s day that we matched for residencies at the University of Washington in Seattle!  She’s going into Pediatrics and I’ll be of course in Family Medicine.  We’re very excited and thankful to have such a wonderful opportunity.



takeoff




sunset at Tortuga bay



Otherwise, I have managed to squeeze in a little catamaran sailing, snorkeling (right after the tsunami scare; the visibility was horrible and everything we did see was covered with sand), more trips to tortuga bay, and if all goes well, I’m bound for some diving tomorrow at a place called Gordon Rocks, which is supposed to be a world-class dive site.  I’ll try and write less and include more pictures in future updates!  Take care.

Tsunami scare

Just recovering from the tsunami scare from yesterday.  My boss Emily showed up at my casa about the time I woke up.  I thought I had overslept but she quickly informed me that an earthquake had hit Japan and we were being evacuated because a tsunami was expected to hit the Galapagos islands in the afternoon.  We went to the office of ICE Galapagos to rummage through the donations I had brought down and grab some diagnostic equipment, painkillers, and a few antibiotics.  Then it was a lot of hurry-up and wait.

Our group gathered at a local house.  Then we planned lunch.  Then we ate.  Then we talked.  Five or six hours after the first news of a problem we finally we loaded up in a truck and headed to Bella Vista, at 100 meters or so above sea-level; certainly a safe place.  Then we sat around in the house where one of the volunteers is staying and watched the news, read, and took a little paseo around Bella Vista to see what everyone else was up to.  No real medical issues came up, and finally we were ready to head back down to town, after the worst was over (we heard about a few damaged boats and waves dirtying the shops along the malecon, the seaside main drag through Puerto Ayora).  Then came the worried messenger; aparently there was a sick baby at the clinic, and he needed an incubator.  Seemed like a strange request, but Emily, another volunteer named Risa (she is also a medical student here in Ecuador), and I headed over to see if we could help.                

 

Septicemia, most likely, said the doctor.  Possibly meningitis.  The baby was one month old and came in breathing poorly and apparently convulsing.  “Do you have anything to help with the convulsions?” he asked.  I had a medication (benzodiazapene) that might have helped but the doctor was concerned about the baby’s breathing.  He wanted phenobarbital, and we had none.  He had given antibiotics but didn’t have everything available that he wanted to give.  I had brought only antibiotics for gastric problems, and the baby didn’t have a fever, so my acetaminophen (tylenol) was no help.  I asked about the basics I had learned for suspected meningitis and septicemia: lumbar puncture? No equipment available and no testing facilities.  Blood and Urine Cultures?  No laboratory facilities.  The baby’s lungs sounded horrible - Chest X-ray?  Machine is in Puerto Ayora and technician retired came the response.                    



Yes, that is a baby under the bucket

The baby was breathing around 60 times per minute (too fast) and working pretty hard to do it.  Because there was no mask available that would fit his tiny face, they had placed a modified clear bucket upside-down over his head with a hole in the top for the oxygen tube to provide a super-oxygenated atmosphere for the baby to breathe.  His oxygen saturation, a measure of how well his red blood cells were carrying oxygen, was good, but he continued to breath too rapidly.  His best chance was a flight to the mainland, but flights were suspended and his condition was so fragile I’m not sure he would have survived the flight.  When we finally did send him down to Puerto Ayora and the hospital, it was around 1 a.m.  I stayed behind and talked with the family while the doctor and nurses made the transfer.  After the doctor returned, I headed to our temporary headquarters and slept a few hours on the couch before being awakened by the roosters, the dogs, a crying cat, and several other sounds I couldn’t identify.  I made it to my home late morning and stopped by the hospital to check on the baby.  About the same, only his heart-rate was down in the 60’s (beats per minute) when I saw him; way too slow.  The family told me that the doctor had said the infection had damaged his heart.   The doctor also said that the baby was in no condition to travel.  I hope that he is able to make the trip to the mainland tonight.

 

  Shortly after I finally arrived at my place, my landlady, who has been on vacation for a month and whom I have never met,  came home and asked how things were going.  I told her fine, other than I had no water and that the toilet was, well, I was still trying to find the appropriately delicate words in Spanish for “the crapper is plugged up and it’s not pretty” when she marched into my room to take a look.  Without a word (or any sign of gagging) she left and promptly returned with the necessary equipment.  She plunged the shitter which had been chronically non-functioning since I arrived.  I was horrified to watch this complete stranger wrangle my duker, but she was unbothered.  As she explained to me that everything was taken care of, I couldn’t help but notice the plunger dripping onto the tiles of my room as she spoke (don’t worry, I’ve since cleaned it up).        

This is not a river!  It's Puerto Ayora!
Swells like the tide every 5-6 minutes
this morning



 

This shows where the waves were during the night -
about 3-4 meters above mean sea level



Puerto Ayora cleanup



She also turned on the water so I don’t have to fill the tank from the shower any longer, and I have another source of water (other than the shower) for cooking and cleaning.    I decided to go back to tortuga bay and then get some food.



cheap eats



                 It’s been an interesting week.



Tortuga Bay

crabs and homo sapiens at Tortuga Bay

Farewell, Guayaquil

This morning my google calendar sent me an event notice - it read:  Santa Cruz, Galapagos (All day)

It was a nice way to wake up, on this fat Tuesday of carnaval, with no plans other than to write a few emails, write an update for the blog, and perhaps visit lonesome George (I can relate, Jorge, my lady is far away, too!).  I went to the beach yesterday, turtle bay, and on the broad, cream-colored beach I caught a glimpse of what is so special about the islands.  While a 2’ black-tipped reef shark patrolled the sand in 4” of water near the shore, a black iguana, slightly longer than the shark, was out near the break, looking more comfortable on the water than when lurching on land.  His black body was completely on top of the water, including his tail, and his gnarled, clawed extremities kept him moving smoothly in dragon-paddle fashion.

Because it’s carnaval, nothing is going on here, and so I’ve been exploring.  I bought a bike yesterday and am currently riding a loner until the bike shop repairs and paints my new one (yeah, baby, it’s a custom refurb; I just hope he remembers to fix the brakes!).  I’ve also been playing my guitar (I’m sure much to the chagrin of my new neighbors) and working on my “Special Project” which is a graduation requirement (and the only one for me that remains!).  More on that in coming editions.

For now, I’m going to miss some of my favorite things about guayaquil – like Batidos (fruit smoothies).  It’s no surprise that this was the best Juan!

 El Mesero (The Waiter)

Cheap eats!  Things are expensive in the Galapagos (well, relative to the mainland).  This is kind of like their version of Hawaii.

The crazy social life I was leading...

  Aviso – lomo de toro!  What is this??  Warning!  Sailors ahead!  Or flying saucers?!  No, it’s a speed bump.  Once you’ve encountered one in the middle of the night at 70Km/hr, you won’t forget!  Thank god it was a rental!  I’m definitely going to miss these.

Creepy mannequins in many of the shops.  And they’re always white people!?  I’m surprised anything sells.

And farewell to the sunrise over the river Guayas.  Hasta la vista.

Cuenca

Yes, I braved las carreteras (highways) again and took a tour to

the mountain town of Cuenca.  Why would I face 2 1/2 hours (each way) of horrific traffic, hidden potholes, unmarked speed bumps, vendors, animals (and sometimes children) in the middle of the highway, hairpin curves, cars without lights or with lights permanently on high-beam, tolls, poor signage, and excessive charges for additional kilometers?  Good questions. 

Well, Cuenca itself is historic, quaint, and, once you get inside the city-center, very walkable.  The food is great and cheap and I had tour-guides thanks to my friend, Cristian, whose brother lives in the city with his girlfriend. 

And I got away from the heat, humidity and mosquitoes of Guayaquil for a day!

 

crop duster spraying bananas

 

sell baby sell!





famous old church





 



Mmmm, lunch!



At the Mirador (scenic view)

Bridge over river Guayas, with Guayaquil in the blurry background

Guayaquil hopsitals

 

Luis Vernaza is the hospital which I have been calling home for the past month.  It is beautiful in many places, disturbing in a few others, and although the lack of access to standard medical care that I mentioned in an earlier blog is an unfortunate fact of life here in Ecuador, Vernaza (owned and operated by the Junta de Beneficencia) seems to do a good job in providing care, and even helping many of those who can’t afford to pay.  It is a well-respected hospital among the people of Guayaquil.

 

Rather morbidly, funeral homes surround Vernaza hospital; I have counted no less than 12 within 1 block of the hospital. 



Patient at Ponce



Another hospital which I visited recently is the Psychiatric hospital, called Lorenzo Ponce.  The abundant grounds were cleaned and managed by the residents, and there were large groups in art and educational classes.  I was told that many of the patients had been abandoned by their families, and that the Junta de Beneficiencia was taking care of them, gratis. 

Today, I visited a state-sponsored hospital, Guayaquil hospital, in the southern suburbs of the city.  In a city of 3 million, it is the only state hospital, and it has 4 floors of approximately 60 beds each, including pediatrics, neurology, internal medicine, and surgery patients, as well as an emergency room and outpatient clinic offices.  



Sharps container














Vendors outside Guayaquil Hospital



The left-leaning government of president Correa has been trying to promote better health-care and access for all Ecuadorians, and this hospital has had some recent renovations and is receiving financial support for improvements.  A new infectious disease wing was constructed with help from Doctors without borders, with a focus on HIV cases, which are numerous in Guayaquil. 

Mobile Business (and more hospital
business coming soon?)