Dr. Nickl is a UK gastroenterologist currently spending an eight month sabbatical in Santo Domingo, Ecuador at Centro Medico Hombro a Hombro and working with the local public hospital.
I have now completed the first half of my time in Santo Domingo, Ecuador. The last couple of weeks have been especially stressful. I’ve begun making gastroenterology teaching and consult rounds with the medicine residents on Tuesdays and Thursdays after I finish endoscopy, and many of the hospitalized patients I see are very difficult. Two weeks ago it was a 45 year old man with the most advanced stomach cancer I have ever seen. So far nearly 10% of the endoscopy exams I’ve done here have found cancer (!), and nearly all are caused by H. pylori, a bacterial infection that comes from contaminated water. This is, therefore, an almost completely preventable disease; but dirty drinking water is the biggest health care problem on earth, which is why gastric cancer is the leading cause of cancer death worldwide. Besides this man’s youth, what made it personally difficult was that, as we stood in the hall discussing the situation, we were quickly surrounded by family who wanted to know about treatments. The residents stepped aside, and suddenly it was me, who had only met the man ten minutes earlier, explaining in broken Spanish that there were no treatments available in the world, and that he certainly had no more than a few weeks left. One by one the family drifted away to huddle together in a corner and hold one another together.
Then last Tuesday morning I arrived at the hospital to find a furious argument underway between Roxanna, the staff nurse regularly assigned to endoscopy, and the head nurse from the emergency room. The cause was the number of patients on the schedule: already twelve, and the ER wanted to add two more. Roxanna was livid, because the hospital is short staffed and there just aren’t enough nursing hours to assign to endoscopy. In fact, Roxanna herself is now volunteering unpaid; the hospital is running out of money and had to let her go (temporarily), but she is volunteering in endoscopy because she likes the work and thinks it’s important. I admitted that, while I’m prepared to work until all the patients are done, it’s really not possible to keep adding to the procedure list when the nurses are scheduled to leave at a fixed time (and one of them is unpaid besides!). The argument set the tone for a somber day, and sure enough we worked very late both Tuesday and Thursday to get through the schedule. I think at the core is the frustration everyone feels that there just aren’t enough resources to go around. The need is very great, and anyone who cares (such as a nurse who continues to work for free after the hospital has furloughed her) cannot help but be discouraged.
But most lingering in my mind is the 33 year old woman I saw in the Centro Médico: personable, attractive, and a bit hyper-dramatic. I was sure she had irritable bowel syndrome, but scheduled an endoscopy just to eliminate anything more serious before starting her on antidepressants. Sure enough, when I looked at her stomach last week she had only a touch of mild gastritis, nothing to worry about. Except, what’s that funny-looking spot up there, in that hard-to-see corner just below the esophagus? I washed it with a little water. Hmm, that’s not right. Wash again, wash some more. Oh, no!
All health care providers learn to establish a certain emotional distance from patients in order to maintain personal stability. But here the tragedies grab you by the collar and pull you in head first. The emotional roller coaster is becoming a bit difficult to negotiate: one day I’m enjoying a lively music concert in old town Quito, and another I’m telling a 33 year old mother of four she has cancer – knowing the cancer was completely preventable. It’s more than a little stressful. However, I know that my work here in Ecuador has been a blessing – not only to others but also in my own life.