In mid-February, just before the reality of Covid-19 took hold in the United States, I was in Loreto, Peru’s largest province, working with a medical team to provide health care to villages generally cut off from such services. These were mainly communities of huts on or along the Marañon River, with limited or no access to running water, toilets, electricity, or cellphone reception.
Little did I know that the trip would provide me with valuable lessons about what I would be facing on my return home.
In Loreto, the clinics we worked in often consisted of school desks covered with tablecloths. Even the most basic personal protective equipment, like gloves and hand sanitizer, were in short supply, if available at all. The types of medications were limited, and the only imaging we had access to was the portable ultrasound machine we had brought with us.
I remember thinking that patient management and care would be so much easier if I had a proper exam table and access to a CT scanner — or at least more than one hand-washing station. I believed that my gaps as a provider would magically close when I was back in the land of evidenced-based guidelines, with ample access to labs and imaging.
Maybe I was uninformed. Maybe I was in denial. Either way, I was wrong.
Three days after my return to North America, the World Health Organization declared Covid-19 to be a pandemic. Since then, the disease has taken an immense toll on Americans, and is pushing our hospitals to the brink. The Society of Critical Care Medicine reports that the U.S. health care system has about 62,000 full-featured ventilators, but projections show that as many as 960,000 people will need ventilator support.
I thought I was coming back to more: More evidence. More testing. More capability. But I’m learning that more does not always translate to better or enough.
As a fourth-year medical student on the cusp of starting my residency, I am familiar with U.S. hospitals and clinics. Simple amenities like gloves, masks, and hand sanitizer come prepackaged with each patient room, safeguards that make you feel like you have some control over the illnesses your patients are combating.
Covid-19 has attacked this security blanket.
The limitations of U.S. emergency rooms amid the Covid-19 pandemic share an uncanny resemblance to the pop-up clinics we held in Loreto. And the lessons learned there are applicable to handling the Covid-19 crisis here in the U.S.
Stepping off a plane in a foreign country can feel both jarring and overwhelming, just like stepping into this pandemic. We’ve been forced to lean into that discomfort.
Providing medical care in a low-income country throws you into a novel environment with new people, culture, and smells. The humidity forces you to spend your entire day drenched in your own sweat. Both are situations that Covid-19 practitioners experience daily.
In Loreto, as we treated unfamiliar medical conditions we had to learn about traditional therapies used in the village. Similarly, clinicians in the U.S. and elsewhere must learn about innovations — real or not — for treating the acute respiratory distress that can accompany severe cases of this viral infection.
Working on global health comes with unpredictable exposures. Before traveling to Loreto, I got vaccinated against typhoid and yellow fever, and took antimalaria medicine every day. Yet that didn’t prepare me for everything. When we arrived in Peru, a major dengue outbreak had struck the region. The treatment for dengue, like the treatment for uncomplicated Covid-19, is little more than supportive care. Prevention is key for both — bug spray for dengue, social distancing for Covid-19. Both work if done correctly and consistently, but neither is 100% effective.
Like many regions around the world, Loreto had limited resources for medical care. We ran short of gauze for dressing wounds, speculums for gynecologic exams, and many other necessities. What’s more, we often could not see everyone who needed help. And only the sickest patients with treatable conditions were sent to the city hospitals for additional intervention. Learning to navigate a novel environment with scarce resources was daunting, but possible.
Learning how to triage acuity and severity was essential to daily success in the field, something that health care workers treating Covid-19 in some cities now do. Although it may seem that decisions on who gets a ventilator or an ICU bed are incredibly challenging and nuanced, we faced similar issues in Loreto. Rationing supplies, adapting workflows, and prioritizing goals are vital skills in places where health care is minimal, as well as in hospitals currently overflowing with Covid-19 patients.
Coping with the reality that not everything is fixable can be challenging for health care providers who find solace in their ability to solve problems. Yet our capacity to design creative solutions is limitless, even when a crisis like Covid-19 makes us feel trapped and helpless. Adopting a mindset of iterative growth will help combat the novel coronavirus more successfully. What worked yesterday might not work today, and that’s OK.
Providing health care in low-income countries forces clinicians to acknowledge the beauty — and the frustration — of the unknown. Timelines aren’t always followed despite the best of intentions. The water will run out. The cargo boat with much-needed medical supplies will be late. The lodge generator will stop. There will be termites in your room. The boat’s hull will start to fill with water — better yet, the engine will fail — resulting in a comical and stressful Amazon River rescue.
Similarly, hospitals, clinics, medical schools, states, and our nation are operating on a minute-by-minute basis during the current pandemic. Each new day comes with the unknown of what our “new normal” will look like. Knowledge about the virus, health policy, state and federal strategies, and even how and when to get groceries are constantly evolving.
Almost overnight, millions of Americans began working from home. Teachers transitioned to distance learning. Hospitals without telemedicine infrastructure rapidly developed it. Patients were moved, physician schedules altered, and surgeries cancelled. States instituted shelter-in-place orders.
Reflection during the heat of the moment is challenging. In Loreto and similar communities with limited resources, is it better to use a less-effective second-line treatment or no treatment at all? What can be done to have a more sustainable impact on village health? What should be done differently on a return visit? Reflecting on the successes, downfalls, aspirations, trauma, and unintended consequences is imperative.
The same can be said about the Covid-19 pandemic. Even as cases and deaths mount and health systems become overwhelmed, exploring the ethics and effectiveness of pandemic-related strategy, policy, and clinical research is essential. Are investigations on Covid-19 being executed with ethically sound protocols? Which communities are being marginalized in the care they received?
I never expected my trip to Peru to have the immediate relevance it does to the challenges our health care system is facing today. As I venture into residency to work as a physician, I’m grateful for the lessons I learned in Loreto and know they will guide my approach to beginning my residency — an unfamiliar environment with new and unforeseen responsibilities.
Like my trip, the Covid-19 pandemic will eventually come to an end. The novelty will fade, the sweat will dry, the adversity will foster innovation, and hindsight will bring additional clarity. Until then, our grit, creativity, and capacity to adapt to the unknown will see us through.
Lakshmi Ramachandran is a fourth-year medical student at Western Michigan University Homer Stryker M.D. School of Medicine with a master’s degree in public health from the Harvard T.H. Chan School of Public Health. She expects to begin a residency in obstetrics and gynecology at the University of California, Los Angeles, in June.
Loreto : LAKSHMI : Lovely
I've set up a Fundraiser for the Awajun tribe stranded in Lima Perú because of the COVID virus. Any help is greatly appreciated: https://www.facebook.com/donate/238259304075374/
thanks for sharing this with us! Great piece!
A very well written incitefull critique of d crisis in d medical field now being witnessed all over the globe though surprising as evident in the U. S. A. Goodluck future doctor. 😷
Fantastic Lakshmi. Very well written. God bless
Thank you for sharing your experiences and insights. I enjoyed reading this.
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