Emergency Medical Services in rural areas of Ecuador; a Primer for Expats

As the author of several books on Ecuador, I spend a lot of time reviewing material on safety, security, and health in Ecuador. Russ Reina a retired paramedic from the U.S. who has lived in Cotacachi for several years has prepared the following primer for expats in Ecuador. I strongly recommend whether you live there or are thinking of moving to Ecuador, this outstanding primer by Mr. Reina should be required reading. Filled with substantial information he provides a unique perspective of a medical system much different then the U.S. or Canada. Some of this information is critical to surviving a medical emergency in rural Ecuador.

Sincerely,

Nicholas Crowder
Author:
100 Points to Consider Before Moving or Retiring in Ecuador
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EMERGENCY MEDICAL SERVICES IN RURAL AREAS OF ECUADOR; A PRIMER FOR EXPATS
BY
RUSS REINA

About forty-five years ago a quiet revolution began in the United States. At that time people were dropping dead on the streets, getting involved in horrendous accidents or suddenly finding themselves in excruciating distress and without anyone to turn to but untrained neighbors and family.

Emergency medicine at that time was practiced in a few University hospitals. Equipped with only a stretcher and an oxygen bottle, ambulances were no more than slightly modified hearses. If, with luck, anyone arrived at the scene of an accident or medical emergency to help, it was likely just an “ambulance driver”, untrained to provide anything but the most rudimentary of interventions.
What changed is that the US, along with most of the “developed” world, deemed it a good thing for non-physician or nurses to be trained in First Aid to be able take action in an emergency. The American National Red Cross (ANRC) spearheaded a move to teach First Aid basics to the general population. Often, the application of very simple techniques can make the difference between life and death.

It was out of this movement that the Volunteer Ambulance Corps grew, which formed the backbone of emergency medical transportation in the U.S. Scattered about were municipal services, hospitals, and Armed Forces facilities. Within just a few short years standardization of services and education became the norm and ambulance services of all types sprang up. Few communities were not covered.

By 1980, through most of the U.S., you could dial 9-1-1 and have an ambulance with a highly trained crew at your door within 10 minutes. You would then be stabilized at the scene and carefully transported to a nearby facility equipped to handle almost any life-threatening emergency.
That was thirty-three years ago. We have yet to see that quiet revolution happen in other than city areas in Ecuador, and even in the big cities, things have yet to be standardized from one area to the next.

The picture I’m trying to paint, without disparaging the local services here which I’ll report on shortly, is that you had better start thinking about your emergency medical preparedness right now. If you wait until something happens it’s possible you will be traumatized beyond your injury.
I was one of the first Mobile Intensive Care Unit Paramedics in the U.S. and lived through the transition from ‘nobody knows nothing’ to ‘there’s always someone there to help!’ (1973 to 1985). As such here’s something important I have to share with you: How the precious minutes surrounding the onset of an emergency are handled by people and caregivers on the scene can make the difference between a prolonged, painful recovery and a smooth path to the restoration of health. That recovery includes for the loved ones trying to offer proper help as well.

Especially in rural areas, it is YOU who must take responsibility for the initial emergency care of your loved ones. This is not because there are sub-standard services but because, like Forest Gump’s box of chocolates, you never know what you’re going to get.

If a country does not have nationwide standards of emergency care, no segment of it can be accused of being sub-standard. Comparing EMS in Ecuador with the U.S. is completely unfair. Let’s put rural emergency care in perspective in terms of the differences you can expect. You have to start with the overall system, beginning with medical training.

In Ecuador, this is the training that physicians go through: In the first two years, basic sciences. In the third and fourth year, the clinical phase, a combination of theoretical and practical classes. The fifth year is called Externado, because you have classes outside and inside the hospital and work there. The sixth year is called Internado Rotativo, and you are called an intern, that is because you are practically living in the hospital. You are hired by the hospital, receive a salary and are considered hospital staff. (paraphrased from http://globalmedicine.nl/issues/issue-7/studying-medicine-in-quito-ecuador/ )

From there you are assigned to a Rural Hospital (Public Health Sector), which includes the facility here in Cotacachi. There are no “permanent” assignments which mean the system here has a moveable cast of characters manning the fort. At some hospitals it cannot be guaranteed that a physician will be on duty 24/7.

According to Andean Health Development, an educational center seeking to raise the standards of care in Ecuador (http://www.andeanhealth.org/about-2/page-3/residency-nurse-training-program/ ) “Physicians and nurses working in the public sector are generally hired straight from medical school with little or no hands-on training. It is AHD’s vision to transform this system of medical training.”

During their last year (in some cases more) in training the medical student’s exposure to emergencies is typically limited to a short-term rotation through the emergency room. The new doctor is assigned to the hospital as a whole and will not pursue a specialty in emergency medicine until after their Public Health service.

Non-city areas do have experienced doctors on staff. Their hours actually AT the hospital, however, are varied and limited and they are not always in town. Sometimes, the Public Health doctor will have more experience than recent graduation from medical school, and there are usually experienced nurses on duty at the hospital. The important thing to consider, however, is that you cannot count on a consistent level of trained personnel available to you in the event of an emergency.
BEFORE YOU GET TO THE ER

Actual treatment of emergency situations does not start at the hospital, however. That is the end point. Getting to the right hospital, especially in Ecuador, is of utmost importance, yet, how you get to the highest level of treatment available can literally make the difference between life and death.

Back “home” (generically describing most expat’s point of origin, the “developed” world) you had a series of safety nets designed to provide you maximum support in the event of a medical or traumatic emergency. You could usually access services within seconds. Here are some contrasts between what was available to you at home vs. what is available to you away from the cities.
#1) NO functional/dependable/universal Central Dispatch.

At home, dialing 9-1-1 would get you to trained personnel who could identify the problem and the appropriate agency to send to help you. If you were in a critical situation the Dispatcher would be able to help you by ‘talking you through’ the crisis until help arrived. If you weren’t sure from whom you needed help, Dispatch would figure it out.

The Dispatcher would locate the nearest appropriate crew and send it to your location from the Police, Fire or Medical units available depending on the circumstances. In medical emergencies, most often the closest unit would be a Fire Dept. vehicle with personnel trained to intervene on a basic level until the arrival of an ambulance with its advanced level of intervention.

Although there is a 9-1-1 system by name, it is not really functional here yet. Many emergency vehicles come through here with “Dial 9-1-1” stickers on them which leads you to believe you have access, but don’t count on having a responsive Central Dispatch system!

1]There is no one trained to talk you through an emergency. If you need assistance you need to know that it is either fire related, of a medical nature or needing Police intervention and call the agency directly yourself. If you think you’ll luck out and get someone on the line who speaks English you are living in Fantasyland. If you have a serious, ongoing medical condition, get its details translated into Spanish and printed out and easily available now.

#2) Don’t expect the ambulance to be able to find you.
Don’t know if you’ve noticed but a house-numbering system is inconsistent at best.
To minimize delay in the event of a medical emergency post in open view in your house or apartment a card or sheet of paper DETAILED INSTRUCTIONS IN SPANISH USING LANDMARKS WHEREVER POSSIBLE of how to get from the hospital to your location so it can be slowly read to the appropriate agency AND THEN REPEATED BACK TO YOU.

#3) Count on Ambulance personnel for TRANSPORT only, NOT intervention
Back home when an ambulance is called either there is one cruising in the area or there are numbers of sub-stations placed around the county where medics await calls. The typical goal of Emergency Medical systems is to have an ambulance at the scene within about 6 to 8 minutes of receiving the call, MAXIMUM!

Systems are set up such that if a town’s ambulances are tied up on calls, a neighboring town’s ambulances will be “moved up” to a position where both towns can be covered. If the ambulances in rural areas are busy, there is no backup.

At home, when the ambulance arrives on scene it is staffed by trained professionals and fully equipped to handle up to an advanced level of emergency stabilization of medical or traumatic emergencies prior to transport to the hospital. Most U.S. based systems also send fire trucks which arrive on scene first. Usually, the medics will take the time to begin treatment on scene and once the patient is stable, move on to the hospital.

If you find it necessary to call for an ambulance you must first call the hospital. Although I’ve been told that there are “quarters” at the hospital for a “Chofer” (driver) to sleep in, it has been reported to me in at least one recent urgent case (3 a.m.) where an ambulance was in the ER parking lot but there was no Chofer available to drive it, therefore the people concerned had to make arrangements on their own.

I cannot ascertain if these personnel are all uniformly trained in basic First Aid, to open the airway or stop bleeding. I would imagine some are. My point is, you shouldn’t count on it.
If one ambulance is tied up, theoretically there is a Chofer on-call. The ambulance is in the parking lot of the hospital. The Chofer is at home or wherever he is (I am not aware of female personnel), on call. He has to get ready (out of bed at night), leave home, get to the hospital, unlock the gate, hop in the ambulance and respond to your location.

My guess is if you set your sights on a one-hour response time you may actually find yourself pleasantly surprised. I have heard of faster response times, but all in all it’s a function of having all the proper elements fall into place at the right time.

#4) You MAY find a Physician and Nurse responding to your emergency and other plusses!
I’m relaying as best I can what you can count on, but let’s just say anything could happen with EMS response here.

The system has an interesting PLUS to it. If there is more than one physician on duty at the local Hospital and one is available, he/she will go to the scene of a true emergency with a nurse and the ambulance Chofer.

Many Ambulances throughout the country are equipped with some advanced technology that the M.D. can use if necessary along with basic intervention equipment. Once again, it is highly limited and there is typically only that one ambulance in town so equipped. It’s fair to say that you cannot expect a doctor and/or nurse show up at your emergency. The immediate needs of the hospital will come first. The appropriate thing to do would be to call and ask if a doctor, nurse and ambulance are available.

To the best of my knowledge, if you enter the country-supported services the ambulance ride is free but, once again, you really need to investigate your area in advance, ESPECIALLY if you are prone to life-threatening emergencies. It is my suggestion that you do a little personal research (ask around) and have a Destination ER chosen in advance for your loved ones.
#5) Don’t expect more than one person to respond and anticipate access to only the most basic of equipment for intervention.

Back home, a bare minimum of two trained personnel in an ambulance would be dispatched to emergencies. Functioning on at least an Emergency Medical Technician level, they would also likely have a lot of cross-training in such things as scene management, extrication, moving the distressed patient safely. You are not likely to have that luxury here. You have no idea what a difference it makes to have two trained people available to work with you in an emergency unless you’ve done the work.

You will have an extra set of hands to work with and a vehicle to move you and not much more unless you there happens to be more highly-trained staff available at the time of your crisis.
My point is you need to start preparing now to consider such things as who amongst your circle will take responsibility to be the Eagle Eye, the Watch Dog, and the Scene Manager to make sure the stricken person is handled properly and transported safely.

Another important point: A lot of the ambulances here are small vans. If it is the only unit available to send to you and you’re a tall gringo you’re not going to be comfortable on the ambulance gurney (wheeled stretcher). This lack of space for movement significantly limits the ability of the medics on board to intervene in multiple-patient incidents as well.

You’ll need two people to lift the gurneys used here. One on either side, squat grab and lift it into the back of the ambulance. Once again, this is something you have to be ready to face and arrange for people to help you on-scene.

OF UTMOST IMPORTANCE: Some newer ambulances in Ecuador are equipped with an AED. AEDs are Automated External Defibrillators (http://en.wikipedia.org/wiki/Automated_external_defibrillator ). But this is something you’ll need to take the time to find out.
I would also like to suggest that you do your own personal research on the use of Aspirin immediately in the event of a person showing signs and symptoms of heart attack or stroke and have it on hand.
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Anyone, even a child, can apply an AED. They are designed to interpret the electrical activity of the heart, decide if it’s critical and then issue the appropriate shock to the heart through electrodes and repeat if necessary.
MAKE SURE YOU DO NOT SHY AWAY FROM USING THE SERVICES HERE IN A CRITICAL EMERGENCY IF YOU ARE NOT PREPARED TO HANDLE IT YOURSELF.

#6) Local emergency rooms are highly limited.
Here, I will speak in terms of “off-hours”. That is to say out of the realm of 8:00 a.m. to 6:00 p.m. The reality is, however, that there is no such thing as regular operating hours. For example the only physician on duty could be part of a critical ambulance transport to out-of-area and the Nurse left on-duty has no emergency experience, or the needs of a patient in the hospital take precedence. This could be any time of day!

Functionally, a limited number of hospital beds means staffing is highly limited. There are a number of local doctors (specialists) on call but they would have to respond from their homes or offices. There is often an Operating Room but no Intensive Care Unit. Any sort of advanced diagnosis goes on at Regional Hospitals for anything needing more than minor care. One of the things this means is the emergency room does NOT have extra personnel to draw from on-site if a rash of medical or traumatic injuries develops.

A person walking into the emergency room from the outside goes to a waiting room and sits until someone comes through the heavy door to usher him/her in. There is no ‘triage’ (reception/ evaluation /admission) desk. You don’t know if anyone is there, who they are, if they can help or when they’ll even come through the door.

On admittance to the small three (or less) gurney room with curtained dividers between them, you will be evaluated and treated within their resources. Count on excellent care for run-of-the-mill emergencies such as falls, cuts needing stitches, eye-washes etc. The hospital is set up to handle you for an overnight stay.

In rural areas, the goal of emergency treatment is to use available resources to stabilize the patient for transport. Options include on scene treatment or transporting to the closest facility though the resources may be at a minimum. The next phase of treatment could be a transfer to a better equipped facility, likely only available in a major city like Quito or Guayaquil. If you can avoid bouncing the patient around without jeopardizing his/her stability, do so.

Here is a review of the level of emergency care available using Cotacachi (serving about 60,000 people) as an example in the event of a cardiac related episode.
You cannot count on the level of experience of the doctor on duty. You do not know if the equipment will work in the moment of your need. Even in a best case scenario our local hospital is equipped with what are called ‘3-lead’ cardiac monitors only.

These were what I used in my ambulance in 1980. They allowed me to review an image of the electrical activity of the heart as recorded from three different angles. They allowed me to see the broad electrical activity of the heart and any ‘dysrhythmias’ or disruptions in electrical activities that were treatable by drugs I carried, or by defibrillation. Whereas the monitors I used had a “print-out” function, where I could read and measure the heart-beat complexes (allowing me to provide the ER doctor with information regarding the choice of drugs, for example) the monitors here only show fading complexes on a screen.

Three-leads were used in the field for essential, immediate intervention in life-threatening rhythms but were useless for diagnosis and management. The next step up from that were ’12-lead’ electrocardiogram machines through which the physician could diagnose the problem and the damage, anticipate other complications and more easily set a long-term recovery plan. The hospital my ambulance served was set up for all of this.

The Cotacachi hospital has 3-lead monitors, no 12-lead machines and, once again, it is difficult to anticipate the doctor’s ability to interpret the info. They do have pain medications that can be administered, which could have an effect on the comfort level of the patient en-route to another hospital.

At home your emergency rooms are equipped with what are called ‘Crash Carts’. They are typically wheeled Craftsman ™ Tool Cabinets standing five foot tall and three-feet wide. They hold drawers and cabinets packed with emergency gear. You’ll find monitors and fifty + different drugs and airways and oxygen advanced intravenous equipment along with everything you need to begin surgery NOW! They also stash more drugs and ‘Bag Masks’, suction machines and essentially anything that you need on hand immediately to handle the secondary aspects of life and death situations (after initial treatment by ambulance personnel) whether traumatic or medical.

In the Cotacachi emergency room I was shown a four drawer (each personal fishing tackle box sized) cabinet, one of which held about fifteen different drugs, most in vials; a second held intravenous equipment and IV fluids; the third laryngoscopes and endotracheal tubes; and the fourth more airways and a “Bag-mask”. There is also an AED, ready to go (but not always!). This is less than half of the equipment I carried in my ambulance back in 1980, and everything I had I was able to use.

The value of a fully-equipped Crash Cart is that “one size fits all” does not apply to emergency situations. In critical moments you need many options to choose from whether it be the drugs you can use or the size of an airway or IV. Remember, this ER is equipped to handle the needs of the Native populace, not the expats who differ physically from them.

CONCLUSION
You must be prepared to manage all the details surrounding the immediate stabilization of the patient directly after the insult and make sure they get to the appropriate emergency room safely. It can involve the local ambulance but be prepared as if you had to take a cab to the nearest adequately equipped and staffed hospital – typically one-half hour or more away!
CRITICAL INFORMATION: There is ZERO value to speeding from here to the hospital. You are seeking “Steady and Smooth” to minimize further trauma to the patient. The amount of time saved between here and there would be no more than a few minutes and the risk – especially on these roads with local drivers – is not worth it. It has been statistically shown there is negative benefit to speeding and in the U.S., for the most part even ambulances don’t speed any more.
It is possible you would receive about the same level of stabilization of your life-threatening condition at the local hospital as you would receive by a Paramedic Ambulance back in the States if you happened to draw an experienced doctor. But still, it would only be a transitional move until you could get your patient to a better equipped and staffed facility elsewhere.
If there is any doubt whatsoever that the patient would survive a half-hour trip out of your immediate vicinity (or you’re not ready to take that responsibility) the next level of care after the incident would be right at the local hospital. But if the emergency can wait even an hour without jeopardizing your patient, once you understand what is available elsewhere, go for a preferred destination.

In anticipation of a potential medical/traumatic emergency, the time to figure out the steps you’ll take to get a stricken individual safely from the scene to an appropriate hospital is NOW.
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Russ Reina has been a resident of Cotacachi since 2013. He was one of the first Mobile Intensive Care Unit Paramedics in the United States. He was the Founder of ¡ExpatRed! Cotacachi where he educated the community and guided it to develop a system of “neighbor helping neighbor” in the event of medical or traumatic emergencies. That organization now goes under the name of Cotacachi Health Chapters. He can be reached at email addressRuss is a writer/artist/performer/musician who has majored in the healing arts since 1969. His non-fiction account of working on the edge of life and death: Moments in the Death of a Flesh Mechanic…a healer’s rebirth available through Amazon and at http://www.russreina.com

EXPATS IN ECUADOR, FUTURE EXPATS – TAKE NOTE – READ THIS ARTICLE FROM DON NADIE