EMS in Ecuador is like Forrest Gump’s Box of Chocolates: You Never Know What You’re Going to Get! What I’ll say may not be comforting, but it could save your life. I'm speaking to my peers, the Baby Boomers who already live in Ecuador and for those others who are contemplating pulling up stakes from North America and coming down to live and/or retire here. To be blunt, if you are here with medical challenges that could throw you into a life-threatening emergency, you must make maximum effort to investigate and prepare in advance for your care from the onset of an episode through recovery; no matter where you live in the country. If you don’t, you may seriously compromise your life and well-being and with it the peace-of-mind and security of your loved ones. Living in Ecuador requires much self-responsibility. Mindo Emergency Clinic in a high-impact sports area for visitors: Two hours to Quito! As an example, I'll use the U.S., but this piece applies to Canada as well. Both countries share demographic characteristics, modalities of healthcare, disease vulnerabilities, and comparable levels of emergency services. This is about emergency intervention in particular, not health care in general. Yet, through the filter of EMS we get to better understand the priorities of our host country when it comes to medical services. Apply what you learn accordingly. When you take a look at the resources and needs of Ecuador you will see how pre-hospital emergency care -- and emergency facilities and critical care back-up -- is appropriate for its population but not geared to handle the kinds of medical problems (and resulting emergencies) the retired expat population carries with it. My review is based on having had 40 years’ experience in the field of pre-hospital emergency care. Twelve of those as one of the first Mobile Intensive Care Unit Paramedics in the U.S. and the balance as a writer examining the human aspects of delivering emergency services. Add to this two years living in Ecuador and sorting through the significant differences between the medical systems and cultures when it comes to meeting the needs of the expat population. Let’s look at that word, “needs” as it applies to our host culture. We must put things in perspective. It is essential to understand that Ecuador is only about 20 years into a major economic and social recovery.
“In 1995, 75.8% of Ecuadorans lived in poverty in rural areas and 42.4% in urban areas. Extreme poverty affected 33.9% of the rural population and 10.6% of the urban population.” (from Innovative Intersector Practice for Health and Equity: The Case of Cotacachi, Ecuador Luis Marina Vega C., August 2007 found HERE).
But today (from HERE) we’re still showing a 49% rural poverty rate with about 22% urban! At its best, Ecuador is still in a precarious balance. The question arises; where are a country’s scarce resources best applied?
Pre-Hospital Ems In The U.S. Was Actually A By-Product Of Affluence.
Having come out of the Depression and through WWII, in the 1960’s, America was getting beyond survival and moving into a new prosperity. Life, rather than something to be endured, was now becoming something worth investing in and preserving. Today, EMS in America is uniform and institutionalized and highly coordinated from one facility to the next. It is very expensive and geared toward servicing an aging population – something that most N.A. expats take for granted and expect they’ll find here. All too often they discover the differences at the worst possible time; in the midst of an emergency. EMS Fact: Did you know EMS didn’t really take off until the appearance of the Jack Webb-produced EMERGENCY! television show (1969)? Pre-hospital care (and hospital systems to support it) was in response to the high incidence of Sudden Cardiac Death (SCD) in the streets of America. The program captured the imagination of an affluent population that had the ability to turn their resources toward equipping and standardizing the advanced care available throughout the country. In Ecuador, the incidence of SCD is very low and basically unchanged since the initiation of paramedic programs. In 1960’s America, when I had my first experience with EMS as a teenager in a car wreck, the backbone of Emergency Medical Services on the east coast of the U.S. was the Volunteer Ambulance Corps that were scattered about. They were not placed through need or design but through the ability of a community to buy a used hearse, modify it to transport a patient, equip it and train a few people in first aid. If someone was available to “run the call” you’d get an ambulance. Pre-hospital care was basically drive like a maniac to the scene, load, and go like hell to the hospital! To the best of my knowledge, even though there are some expat communities in Ecuador who might have the resources, forming volunteer corps of our own is not an option for extranjeros. But that is exactly what would be needed before we could feel somewhat certain that we would receive on-site emergency services and transport to the level at which we are accustomed. And that would only be a first step. The paramedic services that you are accustomed to are part of an integrated system that essentially brings the Emergency Room to the patient. Then, the patient is absorbed into a well-coordinated “Chain of Care” within a series of facilities that address all needs (including psychological, sociological and case coordination) until the patient is discharged. It is a marvel that Ecuador has paramedic services at all! Some people are getting top-notch pre-hospital care. The problem is the services are scattered and not well-tied together. There are not enough trained personnel to go around. Advanced diagnostic equipment, scarce to begin with, is not able to be replaced when broken down. And because the extended family handles most aspect of post-discharge care, EMS functions as one small piece of the puzzle, almost living in a vacuum. Still hobbled by poverty, there simply are not the resources available to bring each element into coordination and make them consistent from area to area; and that is what defines successful EMS! What you are left with is a patchwork of services that may or may not be available, let alone work, when you need them most. This means lots of lost time. Unfortunately, in critical emergencies time without proper treatment kills you.
My Baby-Boomer peers, consider this: You are the by-product of a system that has developed and grown medically mature alongside of you. You are also a victim of it when you attempt to step back in time, which is what you’re choosing to do when you move to Ecuador.
It's Really A Numbers Game!
Any country’s resources go to where they are needed most. Who needs medical attention most in Ecuador? The future. Aged expats are the past. Look at these “Population Pyramids” from 2014 and you’ll understand. Population is defined by sex; male, left, female, right. You don’t have to read the numbers to recognize the “spare tire” on the midriff of U.S. statistics.
About 25% of U.S. population falls into the 50- to 70-year-old age bracket. Because that age bracket suffers from the most debilitating, chronic, and life-threatening illnesses it is clear where EMS resources go. You can pretty much walk in to any hospital in America and find staff at all levels trained and equipped to deal with your maladies within minutes, or they can get you where you need to be within an hour. Now look at Ecuador and you see a completely different story:
How more obvious can you get? About 60% of the population is below thirty years of age! THIS is where the resources are going. The key word is availability. The number of doctors who are seeing patients with relatively complex and comparatively “exotic” conditions of age on a regular basis is dismally small. Here, it’s important to note that the effectiveness of medics in emergency situations (from medical technician to physician) is directly proportional to the amount of experience they have in dealing with that particular emergency. Expertise with aging expat emergency problems is limited to a select few in the country. When only about 6% of the native population is in the expat age range, you can rest assured (or is panic more appropriate?) that you have to go far and wide to find a doctor that can treat what you have. Especially when you need it most! Where you’ll find doctors with the most experience in the health problems of aging expats will be in private clinics and/or hospitals. That means it’s going to cost. If you don’t have an airtight insurance policy you’ll need cash on hand to assure you’ll be treated without delay or have more extended care available to you. Consider this: If the only cardiologist in your area has, for example, a day off, chances are you're not going to have an equally trained practitioner covering his back. The numbers of people affected by cardiac problems simply do not justify having backups upon backups which is usual business in the U.S.
But What About Population Centers Like Quito?
Most expats would guess if you’re going to have good emergency care, it would be Quito. But surviving the ER is only the first step of many in an integrated system. Critical cases need a very advanced next step of intervention that takes place in units equipped to deal with specific issues. Try this out: GOOGLE “intensive care unit Quito”. What do you find? Entry upon entry about infectious, mostly childhood-related diseases and intervention. Now try “coronary care unit Quito”. Have you ever seen less useful information come from Google? What’s the best hospital to go to? I hope you see what I mean about preparing way in advance of a heart attack or the like. You need to obtain a doctor who is familiar with your case, is willing to be at your side in a moment's notice and has at his disposal the equipment and personnel necessary to save your life and also make sure you have somewhere to go once you leave the ER. One of the biggest complaints of retreating expats is the lack of emergency protection. And nine times out of ten they don’t find that out until they’re at death’s doorstep. Norteamericanos simply do not think about emergencies because they have been trained to assume all will be taken care of. Ecuador, for so many solid reasons, is attracting a steady stream of expats coming here to settle. The general word going out is that healthcare here is both good and relatively inexpensive. This is not being dishonest but it lures the potential expat into a false sense of security because healthcare is healthcare, isn't it? It is NOT when it comes to emergencies arising out of lifestyle choices that weaken the body and then are treated by the North American physician's tendency to overmedicate. If you’re over 50 with very serious Norteamericano illnesses the only place you can live safely is within a block or so of one of the five or six hospitals in the country that can handle your particular problem. Next, let’s look at the top ten causes of death in the U.S. and Ecuador (RATE per 100,000 population): Top 10 Causes of Death -- United States 1. Coronary Heart Disease 80.48 2. Lung Cancers 35.38 3. Stroke 25.36 4. Alzheimers/Dementia 24.84 5. Lung Disease 24.32 6. Breast Cancer 18.80 7. Diabetes Millitus 15.16 8. Road Traffic Accidents 13.88 9. Colon-Rectum Cancer 12.63 10. Hypertension 11.40 Top Ten Causes of Death -- Ecuador 1. Coronary Heart Disease 39.85 2. Diabetes Millitus 37.05 3. Stroke 34.53 4. Hypertension 33.26 5. Influenza/Pneumonia 33.20 6. Stomach Cancer 24.64 7. Violence 21.67 8. Road Traffic Accidents 20.39 9. Other Injuries 19.65 10. H.I.V./AIDS 18.24 There is more than double the rate of Coronary Heart Disease in the U.S. Another two of the top five (U.S.) are lung-related at 60+ per. Alzheimers/Dementia -- #4 in the U.S. -- is the 46th cause of death on the Ecuadorian Chart! These proportions would roughly be duplicated in the expats population. An American is susceptible to death in just these ways. The high incidence of lung-related diseases for US expats is foreboding; more than half of Ecuador is at high altitude. And, finally, three of the top ten causes in America are cancer-related, whereas three of the top ten in Ecuador have to do with trauma.