Never one to do something the normal way, when my nurse practitioner residency started, I opted to expand my horizons and venture to the southern hemisphere in Quito, Ecuador. Doing my residency in the Ecuadorian health care system was one of the most profound and life changing experiences I ever had.
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The first week was rough. My luggage did not arrive for 4 days, it was cold and wet, I was battling the high altitude at 10,000 feet, and to make matters even worse, I had a gnawing, stabbing pain in my ribs that made it difficult to sleep, breath, and move. Within my first week of being in Ecuador, I found myself experiencing the health care system first hand. I had to go to a local hospital and get chest x-rays, purchase an unknown medication that I was given a prescription for from a local doctor whom I hardly knew, and place my trust in the hands of a health care system that I did not yet trust. In fact, trusting in the health care system was a challenge in and of itself. Although I have spent some time volunteering as a nurse internationally before, I found myself completely unprepared to deal with what I would soon experience both personally and as a nurse practitioner.
My perspective of global health completely changed in "Sala de Partos," the labor and delivery unit at a public hospital in Ecuador. "Sala de Partos" was a basic operating room that had several stretchers lying side by side. Women were admitted here for various reasons: they were in active labor, they had problems with their pregnancy, they miscarried, or they had a fetal demise. They had no privacy and the environment certainly did not give them a sense of dignity. They were young, scared, and alone in this process. Taped on the wall, as if it were an afterthought, but definitely not a practice honored at this facility, was a journal article citing that there were less birthing complications in women who had the support of their family during the labor process and furthermore, that it was the right of a woman to have the support of her family during this time.
Each woman was assigned a stretcher, where she would lay on her back with only the package of maxi pads she had brought with her to serve as a pillow. If she were lucky, she had a sheet to cover her. There were no pain meds, no epidurals, and their IV poles served as the one thing they could grasp onto when the intensity of labor struck them. They would arch their backs and cry out saying "No puedo! No puedo!" ("I cannot! I cannot!") This was a task that they would have to complete alone.
It was in this place that I met Ana. Ana was a 29 year old G1 P0 who had ruptured her membranes almost 24 hours prior and was now facing the sting of intense contractions as her baby desperately tried to enter this world. She grabbed hold of the IV pole and her face turned beet red as she cried out in pain. She lay on her back, sitting in a pool of blood, urine, and feces, her thin blue gown had been pulled up revealing her perineum to the group of first year students who stood around talking about her case as if she wasn't there. I, too, was among that group. This was rounds after all. I had to analyze the case and try to answer the questions right. Yet, something in me hesitated.
I walked up to her; she looked at me, sweat was dripping down her face and her eyes were full of fear as if to tell me she could not go on anymore. I grabbed hold of her hand. It was as if in that instant it didn't matter that I was a white woman from a strange country who has never experienced child birth; I was a presence to her, a comfort in a time when comfort simply did not exist. For a moment, I had set aside my note taking and question asking role and became her source of support. She held onto my hand tightly and I coached her through labor all the way until the delivery of her son. She had never let go of my hand and she turned to me with a smile on her face and simply said, "Gracias" with tears streaming down her cheeks.
Ana's lesson to me was that often it is the simple things that make the difference in the lives of our patients. Sometimes, we get caught up in all the data and facts and forget that we are dealing with a human being who isn't as concerned about data as much as whether they are going to live to see the next day. They are not as interested in our medical rounds as they are in keeping their dignity and being respected. We are here there for them; they are not here for us. Sometimes all they are asking for is a hand to hold and a comforting presence.
Ecuador was a place that many times, challenged my educational foundation and personal values. There were a times that things were said and done that I didn't understand. It was so easy for judgment to creep up into my heart. It became very evident that I was dealing with a system that faced severe challenges: lack of resources, widespread poverty, infectious diseases, and poor sanitary conditions. Perhaps some of things I saw could have been handled differently, or perhaps everyone was just doing the best they could given the circumstances.
Studying in Ecuador was more than just learning clinical practice, it was about learning the culture and expectations of this population and the relationship they have with their doctors. It was about learning that our ways are not the only ways; they are just different ways, like how to care for people when you don't have the luxury of diagnostic testing and monitoring. It was sometimes about setting aside my opinions and being open to learning and understanding their ways. My time in Ecuador was an experience that I will recall for years and that will forever influence the way I practice health care.
