More pictures of our trip to Paquisha

stuffed in taxi back seat, all five of us. 

Emmett and I helped with setting up the eye exam and  eyeglass dispensary at a makeshift clinic site based at a Catholic Church where Kate saw patients. 

Emmett and I attended Mass while Kate was seeing patients.   It appears that the Sacrament of Confirmation was celebrated

Motorcycles are a common form of transportation

typical housing in the countryside 

Annalise hiking to the falls (see Kate's blog entry)

Kate seeing patients during a very basic encounter with no exam room 

a possible Christmas card photo?

Kate had a busy day

dulce

Today's adventure - "jornada" to Paquisha

Today (Sunday) we had a scheduled outing to a town called Paquisha, about an hour away from Guadalupe.  The local priest, who is apparently a very dynamic guy, had reportedly done lots of local advertising for our services today.  Lots of people come from the surrounding area to go to mass in Paquisha on Sunday, so it tends to be a busy day in town.

We had a "taxista" (taxi driver) from Guadalupe drive all of us in his pickup truck.  By all of us, I mean our family of four, and three of the clinic staff -- envision the driver, 2 people in the front passenger seat, 4 people squeezed in the back, and 1 person sitting in the bed of the truck with the boxes of medicine and eye glasses to sell at deep discount.  The mountain roads are very curvy and winding, some stretches are paved and some are dirt roads.   It was all going along fine at first, and then the pickup started to sputter and stall.  The driver was concerned that the gasoline may have been either dirty / contaminated or diluted -- he got the truck to putter along for a little while, and then it stalled out entirely in the middle of the street in a town called Zumbi (about halfway to our destination).

We managed to hail another similar taxi, we transferred all the boxes over to the new pickup, and we were on our way again.  We made it (albeit a bit late) to Paquisha and set ourselves up in the side room of the local church.  John and Emmett helped set up the glasses, and John has learned how to do simple eye exams and help figure out what strength of glasses someone needs.

Meanwhile, we set up the medical side of things while patients waited at the door.

Over the course of about 4 hours, I ended up seeing 30 patients.  These field trips are an extremely simple form of practicing medicine -- with no records, no charting, no history, no medication lists, etc.  I would estimate that about 80% of the people I saw had some combination of the following complaints:  headache, watering eyes, gastritis (stomach inflammation), and/or knee pain.  I had a list of medications that we brought with us, and basically dispensed a lot of Tylenol, antacids, and artificial tears eye drops.  I had essentially no diagnostics available to me, and I didn't have an actual exam room so the physical exam I could do in a room full of people was very limited -- so I was going solely on clinical experience.  I punted the patients with what seemed like more complicated medical issues back to the local health center, where they are usually seen.  (There seems to be a very real lack of primary care continuity, which is a shame, as everyone can benefit from that.)  Everyone seemed thankful for my time and attention, and there isn't this sense of being entitled to live a pain-free life like there is in the U.S.

After we finished, our taxista drove us up to see a pretty waterfall about 20 minutes away.  After sitting with patients all morning, I was really happy to stretch my legs.  At first we thought this was it...

...but then we hiked about 15 minutes up a little trail to the side...

and found out that this was it!

It was very pretty, and worth the little side trip.

It has been a long day -- and we are learning more about our new home all the time.  More to come.

Initial challenges

Today is day 3 in Guadalupe, a beautiful and peaceful town.  We are fortunate to be here.  Inevitably, though, there are growing pains.

If you are going to seek out an experience like this, you have to be willing to roll with it, and to operate in the "plans are made to be broken" mentality.  I have been well aware of that -- and sure enough, we have had to roll with quite a bit.

Our initial plan was to arrive in Quito, take care of our visas, and then come down to Guadalupe with a week or two to set up our lives before I was to take over seeing patients at the clinic.  So much for all of that!  In order to get our visas, we have to get some paperwork from the big Catholic church office in Ecuador, saying that indeed I am performing a legitimate service, not getting paid for it, they are providing us housing, etc.  They also send someone from the Catholic office over to the visa office to help us out with the process.  Alas, that office was closed for vacation for the entire month of August -- so we will have to return to Quito in September to get that accomplished.

The bigger item is that I have had to take over the clinic duties ahead of schedule.  There were 2 doctors (a husband and wife team with grown children) who were scheduled to be here through early September.  As the clinic often only sees 5-10 patients per day, they were wanting more work -- so the clinic coordinator scheduled several day and evening trips to surrounding towns, where they could see extra patients.  Unfortunately, the daughter of these doctors had some complications of her pregnancy at 30 weeks or so, and they had to fly back home unexpectedly at the last moment.  The clinic coordinator apologetically emailed me and asked if there was any chance we could come down a little early, and whether or not we were willing to do these outings.  They sounded kind of fun, so we said OK.

As it turns out, it has all felt a little bit overwhelming.  On my first day in the clinic, we were scheduled to leave a little early and go to the larger town of Zamora for the evening.  It turned out that I had 12 patients to see before we left, on my first day with a brand new clinic system and EMR, not knowing what meds were in the pharmacy, etc.  I managed to get through it (though with many charts still open), and then we went and saw at least 15 more patients in the evening.  All of this on my first day!  Whew.  Yesterday I also saw 12 patients in the clinic, and managed to catch up and get all the charts closed from the previous day.  We then have an all day outing planned on Sunday, which I suspect will be VERY busy.  I'm not sure how to feel about it -- we will see how it goes.

Really, this is kind of the worst time for me to be doing all this extra work.  We need to investigate schools and get the kids signed up.  I have not even really had time to walk around the town, and figure out where to buy things.  Honestly, I am feeling a little overwhelmed.  I'm sure it will sort itself out, and I will probably need to ask for some time off to arrange our lives.  It's just hard to set those sorts of limits when you're the only doctor in the place.  There is always a balance to be struck between service and self-preservation.  I feel this particularly as a parent, wanting to not only set myself up for success this year, but the kids as well.  They are troopers who are indeed "rolling with it," and are really making the best of things.  But the balance of responsibilities is a challenge!

Online in the "Cloud Forest"

Today is our second full day in the village of Guadalupe.   Our journey from Quito to Guadalupe took  eight hours.    The plane ride from Quito to Loja was less than an hour and then we travelled 2 1/2 hours by taxi pickup truck to our new home.   We opted to travel by plane rather than spend 13 hours on a bus.    The taxi drove us through steep and winding mountain roads and we passed by evidence of recent mountain slides which routinely interrupt mountain travel.   The passage from urban to rural living is marked by the style of housing.   Loja is a city of 30,000 people and much of the housing consists of homes built on hills connected to each other.   Many do not have windows but use metal or wood shutters.    Nearly all of the houses have clothes lines with daily laundry on display on roofs or decks.     Here in Guadalupe the houses are one or two stories and are very much integrated with the neighborhood.   Due to the hot weather, many of our neighbors socialize outside in front of their homes.   Some lunch and dine outside at makeshift stalls where soup is served.    I have learned that pigs are butchered occasionally outside our apartment near the river which we surely will hear.
Guadalupe is a village of approximately 800 people and is situated on a river.   Life here is very much    different compared to the big city of Quito.  The people of Guadelupe depend on the land and animals for their livelihood.   In the very early morning we hear horses hooves and roosters and dogs barking.   Most people we see early morning are carrying machetes.  
We now live in an apartment building located near the river.    There is a foot bridge (with some missing boards) that connects the village to the Catholic Missionary compound.   Emmett and Annalise have met the neighborhood children and seem to be having fun.   We arrived at our new home at 9 in the evening on Tuesday and Kate started working on Wednesday morning.   She had a busy day seeing 12 patients until 3 pm.   Then all of us got in a taxi pickup truck to travel to the Catholic administration building in Zamora where Kate saw another 15 patients.   Emmett, Annalise and I helped dispense over a 100 reading glasses.    We helped with cursory vision tests and dispensed  glasses for $5 each.   Emmett was courteous with the customers and I was pleased to see him experience the challenges and rewards of helping others.   We finally arrived home about 8:30 that night.
Today, Kate had another busy day in the clinic but has the evening off.     The clinic staff has been very gracious and welcoming.   Father Jorge, who manages the Nuestra de Señora Guadelupe Mission, is on vacation until next week so we have not had the pleasure of meeting him.   We have waved and said "hola" to a few of the nuns but have not met them.   Our apartment is new and clean.    Our neighbors all seem friendly and everyone seems to know each other in such a small town.  We have not decided where Emmett and Annalise will go to school but all of the options are within walking distance.    Emmett has been playing soccer with some new friends on a covered concrete court in the center of town, one block from our apartment.    Annalise met some new friends and went over a playmate's house today to paint an "Ecua-Oso" which is a bear painted in the colors of the Ecuador flag.
John

Kate's first day at the Mission Clinic

Annalise climbing on their bunk bed

The foot bridge across the street from our house leading to the Mission compound

The river separating the village from the Mission compound

The house across the street from our apartment building 

Annalise and Emmett on our deck (notice the people carrying leaves across the bridge)

Our neighbor's truck 

The foot bridge leading to the Mission compound

Annalise and Emmett walking toward our apartment building

Our apartment building (we live on the second floor)

The Mission chapel 

house next to our apartment building

Emmett making friends

Soccer game: Aucas vs Mushuc Runa

The kids and I went to a pro soccer game today -- a local Quito team called Aucas, vs. a team from central Ecuador called Mushuc Runa.  One of our Spanish teachers, Patricio, who is a soccer fan, offered to take us to the stadium and see the game with us.  Aucas stadium is in the poorer south end of Quito, and Patricio explained that Aucas is "the team of the poor people."  As such, not a lot of people were at the game.  Neither team has a lot of money, and so they don't attract the best players.
It was a lot of fun, even though Mushuc Runa won 1-0.  The kids alternated sitting with me, and sitting down by the fence next to the field.

... you can get a sense of the feel of the experience here

The fan band was right behind us, which made it more fun and exciting, but Annalise got tired of all the noise and said it gave her a "chest ache"

Ice cream always helps in those situations.

The drummer behind Annalise asked her to stand up with a team sign that he made -- which was happy to do after the ice cream pick-me-up.

We were sitting squarely in the sun -- and though the air temperature doesn't get much above 75 F, the equatorial sun is SO strong.  Even clad in hats, long sleeves and pants, and 70 SPF sunblock, we were pretty wiped out afterward.  Still, we've had worse days.

Some quirky things about Ecuador

When you come to live in a new place, there are some things that jump out at you immediately as being different from your country of origin.  Here are a few things that we have noticed, that we really don't even think about in the US.

1. Hot water, such as it is, is warmed up as it comes out by an electrical apparatus that is attached to the shower head.  We are all trained from a young age to be very concerned when electricity and water mix -- but somehow this seems to work (kind of -- our showers are intermittently lukewarm and intermittently pretty chilly).

2. Have you ever wondered what happened to all the 50 cent pieces and dollar coins that were supposedly minted by the US, but we almost never see them in circulation?  They are all in Ecuador! They use the US dollar as the currency here, and people use dollar coins super commonly like we use quarters.  They are really handy -- for example, it costs 75 cents for all of us to ride the bus to Spanish school, and those coins are really useful.  I suppose in our increasingly cashless world in the US, they wouldn't be used as much, so rest assured that those coins are being appreciate by someone in the world.

3. You can't put toilet paper in the toilet here -- it will clog up the pipes.  There is a little waste basket with a top next to every toilet.  That one takes some getting used to -- talk about things you don't even think about in your normal day!  Also, public toilets cost about 25 cents, and the attendant hands you some toilet paper after you've paid.  It's a good motivation not to sneak in without paying.

4. Plans change without notice.  For example, we had plans to go to a big professional soccer game, which was to take place on Sunday at noon.  It turned out that one of the teams was knocked out of the tournament, so they changed the game time to Saturday at 4pm.  That would NEVER happen in the US -- there would be mutiny.

5. Motorists do not stop for pedestrians as a rule -- it is more like they are actually trying to mow you down.  Where we live in the Pacific Northwest, if you put one toe in the road traffic will come to a halt.  On the busy and bustling streets of Quito, we have had to be really careful in a way that we are not used to anymore.

6. Safety standards are really different.  For example, to get in and out of our apartment, we have to go through 3 locked doors.  While that is good for security, you have to use the keys to get out too -- such that you cannot get out of the building unless you have your keys with you.  It seems like a major fire code violation to me.  Also, if one of us wants to go out while others stay home, the homebodys either have to go from the 3rd floor down to the street and let the itinerants in and out, or the itinerants take the keys and leave the homebodys with no way to get out of the building in the unlikely case of emergency.  Yikes.

Chula Vida!

At our favorite outdoor food truck plaza: "Life is Cool"

Annalise and Emmett's greeting for Mommy's late night arrival to Quito. 

Annalise and Emmett taking a break from Spanish lessons

Sunset from our apartment deck 

Morning moon visible from our deck

Annalise eating a breakfast snack in the early morning cool air 

As if Emmett did not stand out already, he had his haircut at the Dominican barbershop next to our Spanish school.