[This post was submitted by Bryan Tepper, a third-year resident in emergency medicine at UNC. His travel was supported by the EM residency program]
Ecuador is a mecca for biodiversity. Earlier this year I packed my backpack looking to experience adventure and immerse myself into a new culture and health care system. Andean Health and Development, a U.S.-based health NGO, provided me with the opportunity to work alongside Ecuadorian residents who are tackling not only myriad patient complaints, but also the challenges of rural medicine and limited resources, which are things not typically experienced by residents training at tertiary care centers. Pedro Vicente Maldonado Hospital is set in a lush mountainous region and reached by a two-hour journey west from Quito, the country’s capital. Given the seemingly third-world feel of the town and its surroundings, the hospital itself is something of an anomaly, as it offers a wide array of services, from emergency medicine, inpatient care, surgery (two days per week) and even specialty services. I was fortunate enough to witness the frenzy that was stirred up when the urologist came into town: 60 people, mostly traveling on foot, were lined up outside the hospital front entrance before 6 a.m.
In general, we confronted patients with typical, bread-and-butter complaints with a sprinkling of exotic diseases and machete-induced injuries. One morning, however, proved to be an unforgettable white-knuckle experience.
A 4-month-old baby boy was rushed to the acute care area by his mother. His skin was a dark bluish hue resembling the ocean floor: cyanosis resulting from a lack of oxygen to his tissues. He let out an intermittent, feeble cry and was not responding to any external stimuli.
With the mother at bedside the team began to resuscitate the distressed infant. Adequate oxygen to the tissues is typically defined as an oxygenation saturation greater than 85 percent – our patient could not get above 32 percent. We attempted to reposition his airway to ease the flow of air into his lungs but this was futile. We applied a mask from a tank of pure oxygen, but once again, this was to no avail.
With differential diagnoses bouncing back and forth across the gurney, our main priority was to somehow increase this child’s delivery of oxygen. In the midst of the controlled chaos I inserted a tiny tube of plastic into the child’s airway, hoping we could get oxygen directly to the baby’s lungs. Intubating patients is something I am familiar with, but doing so in a foreign land and pushing my medical Spanish to the limit are not challenges I typically face.
The tube was in, yet for some reason the child was still blue. We got a chest x-ray to evaluate the lungs and positioning of the tube. The tube positioning was sufficient, yet looking at the child’s heart, I was reminded me of the once-ubiquitous Ugg boots. What did this mean? It meant the child had a specific congenital heart defect, Tetralogy of Fallot, in which there is not just one, but four, defects to the heart, as the name would imply. The child was succumbing to a defect he was born with, and is something that is usually recognized—here in the U.S. anyway—either in-utero or shortly after birth.
With no ICU, no pediatric specialists and definitely no access to cardiac care, we needed to transport him to Quito, and fast. Ecuador is notorious for its twisting roads riddled with pot holes and for exceedingly high rates of motor vehicle accidents. In addition, the ambulance services in this part of the country are meager at best: a bed, a tank of oxygen and someone to drive.
This meant we would have to accompany the patient if he had any hope of surviving. We piled into the van with trepidation and pre-filled syringes of medications, just in case the child’s heart stopped beating. We sat on the front of a wooden bench, and the boy’s mother watched over our shoulders as we squeezed a bag every three seconds, giving breath to the tube in her child’s mouth. The driver raced and maneuvered past buses and livestock in an attempt to shave thirty minutes off our predicted travel time. To make the situation even more harrowing, the sky opened up, eliciting a downpour. After all, we were in the rainforest. Between the rattling benches, screeching tires and roar of the engine, listening to the child’s heartbeat was almost impossible. At times we literally had to slow down and almost come to a complete stop just to confirm that the child’s heart was in fact beating. At one point, our oxygen tank ran out. We stopped on the side of the road, and the driver—seemingly magically—pulled another tank out from under the van.
By the time we reached Quito (not even knowing whether one of the main hospitals would accept our patient), my hands were so fatigued from bagging, I could hardly open them. We eventually found a hospital to accept our weakened and still dusky patient and his courageous mother. That day proved to be a definite struggle to give breath in the Andes.
- Bryan Tepper