Sacred Valley - Day 24 Symposium Update

6/28/2012

What a week it’s been.  Over the last two days, the group has been on double duty – staffing both clinics and a health care symposium organized by Dr. Morales, the local physician who has been instrumental to our success.  Speaking on a variety of topics as requested, the symposium attracted health care workers from mountain villages, physicians and medical students, and physical therapists all the way from Cusco (more than an hour’s taxi ride from Pisac, where the symposium was held.)  We covered several obstetrics and pediatric topics, nutrition, hygiene, and exercises to relieve back pain.  Clark even brought props, and some of the health care workers were able to practice their CPR skills.

Practicing CPR 

During the lunch break, I spoke with a medical student who was eager to know about PDA (patent ductus arterious) management in the United States.  (A PDA is a normal part of fetal circulation and closes within 2-3 days after birth.)  As we conversed, I learned that in the higher altitudes of Peru, PDA closure is delayed till up to 21 days after birth due to the decreased oxygen in the air at higher altitudes!  In the end, I learned more from him than he did from me, and these types of exchanges of knowledge make international healthcare absolutely fascinating to me.

Those of us who participated in the symposium agreed that the best part for us was watching Dr. Morales show the attendees the supplies we were able to provide for local clinics.  He was simply beaming at his new acquisitions, including nebulizer masks, electric thermometers, blood pressure cuffs, pediatric bag valve masks, and more.  Our next goal is to help bring an x-ray machine to the Pisac clinic.  With the nearest one currently all the way in Cusco, this would be an important addition the healthcare system in this region.  Who’s up for the challenge??

In the meantime, those not speaking at the symposium fielded two very busy clinic days!  Yesterday, we were at a local school and saw about 130 patients, mostly children.  And today, a last minute schedule change resulted in the group opening clinic in the city center of Urubamba.  Even with these unforeseen circumstances, we were able to see 160 patients today.  The student leaders have done an absolutely phenomenal job in keeping us organized, and that was never more evident than today.

Erica and Lisa seeing patients

Tomorrow marks the last day of clinic for this year.  It’s been an amazing experience for all those involved and we look forward to returning next year.

Rachna May, MD – CCF Pediatrics

Sacred Valley - Day 23 - Glasses Update

Today we stayed closed to home and visited Arco Iris, a school in Urubamba for children with disabilities. It's always been particularly fun and memorable to work with kids while here in Peru. Although some come to clinic quite sick, many are funny, engaging, and very loving, despite a significant language barrier. My Spanish is very beginner and my Quechua limited to a few words, but in the past fews days, I've received hugs and kisses from my little patients, or have been lead around the clinic by someone half my size. As we set up our clinical stations today, many of the students kept their distance, but one boy came over very eager to play catch with his soccer ball. A little later, a 3 year old girl was very curious about my suitcase full of supplies, and as soon as I emptied its contents, she climbed in and looked like she never intended on leaving. She was very interested with playing with my hair and took great care combing it with her hands.

Although most of our patients today were children, we were very busy on the adult med team. Many of our patients had the same complaints we've seen over the past few weeks - back pain, cough, and vision problems. I've spent a lot of time in the vision clinic over the past week testing vision and fitting glasses, so it was interesting seeing the cases from the medical perspective and hearing the patient's vision history. With help from the senior medical students and attending physicians, I've become more comfortable testing for strabismus, red reflex, and cataracts, and identifying pterigium. Today in the adult med clinic, I successfully identified early stage bilateral cataracts in an older man presenting with vision loss. The patient was a bit disappointed to learn that he had cataracts, but I was excited to inform him that another medical team arriving in a few weeks could perform cataract surgery that would improve his vision. Making these referrals has been particularly rewarding because there is a good chance that our clinical visit will drastically help improve a patient's physical well-being.

Working in the vision clinic can be particularly rewarding, because with the right pair of glasses, we can help someone see clearly, often for the first time in many years. My first day working in the vision clinic last week, four Quechua women came up to kiss me, thanking me for their glasses. Unfortunately, we are not always able to fit everyone with the right pair of glasses. Over the past few weeks, we have given out hundreds of glasses, but recently we've run out of the lowest power distance vision glasses. Many patients complain of blurry distance vision and are able to read the majority of the eye chart, but we have no glasses left to give them. It's particularly hard to send these patients away empty-handed, after they have waited patiently in line for several hours.

Sunglasses and eye drops (gottitas) are extremely popular everywhere we go. Pterygium is very common, and many patients complain of itchy, watery eyes. Due to the hard work and diligence of our glasses committee, we have many pairs of sunglasses to give out to help manage this problem. I try to make it very clear to each patient the importance of wearing sunglasses to protect their eyes from further damage. I like to give each patient a choice between a few pairs of sunglasses and often hear "mas chico, doctorita?" Many different types of sunglasses have been donated, and it's very amusing to see which pair the patient with pick. Many patients often get input from others waiting in line, or laugh when I offer them a pair that they think is particularly silly or unusual.

Working with the vision clinic has been extremely fun and very rewarding. It's given me an amazing opportunity to work individually with patients and to improve my Spanish. While sometimes I feel that our assistance is limited to multivitamins and ibuprofen, helping an individual see provides a very immediate sense of relief and satisfaction. I am very thankful to all who donated and collected all the glasses and sunglasses - they have been very gratefully received!

Julia Liebner

MS2, Case Western Reserve University

Chincha - Week 1 Recap

Wednesday June 27, 2012
After a fantastic week in Urubamba and Sacred Valley, and an enjoyable weekend in Cusco and Lima, I joined the Chincha team on week 3 of the Peru trip. Chincha was different in that it was more urban, we were stationed at one Health Clinic site the entire week, and we also had access to some specialists.

At the Chincha Clinic I had my own office and cadre of translators and sharp medical students assigned to work with me. However, I also had 35 patients on my schedule on day 1. As an internist in training who barely speaks a lick of Spanish, I knew it would be a challenge. We made it through the day, and each day after felt a little bit easier despite what seemed to be a continued increase in patients. At times, buses of patients would show up at my door despite an already full schedule. Turning patients away wasn’t an option, so I’d recruit some help and get down to work.

Along the way we saw a ton! End stage rheumatoid arthritis, esophageal cancers, gastric cancers, severe Vitamin B12 deficiency, hip fractures, self-inflicted severe testicular ischemia (yes, you read that right), severe hyponatremia, septic knees, congenital hypothyroidism, and much more. Our tools were limited, so reliance on a good physical exam was crucial. Knowing we had access to basic tests and procedures, on day one I ordered an EKG and pulmonary function tests on one patient. A few minutes later a medical student came back with a conveyed message from Dr. Zambrano (the fantastic Peruvian cardiologist who spearheaded the Chincha mission) stating the tests weren’t currently available and that I should “treat them like we’re at war”. Yes there was limited access to procedures, but it was a reminder that history and physical would be our primary weapons. There was an ultrasound, but an ultrasound tech was usually not there, so at times I would just do my own ECHO’s or perform my own abdominal ultrasounds.

Many Chincha moments will forever remain etched in my memory. I remember sending patients to the hospital emergently. Transport is different there as ambulance is not all that common. Instead we put the patients in a cab and send them stat to the hospital. I remember feeling great after treating an incredibly kind elderly gentleman with ataxia who was found to be severely vitamin B12 deficient, but then feeling hopeless when I realized he was deficient because he simply could not afford food. I remember David Xu our medical student taking an astute history on a patient and discovered she had black stools. We referred her immediately to our wonderful GI specialist from St. Louis Dr. Walden who did an EGD and found a gastric mass. I don’t know what treatment options are available and what the outcome will be, but at least she now has a fighting chance. The next day she came in and thanked the team with 2 cans of homemade chocolate bean dip!

From a professional standpoint this was a growing experience for me, as I gained confidence in my ability to handle a high patient volume and also my ability to diagnose without all the fancy lab tests and procedures we have available to us back home. It also made me appreciate the training I had received at Cleveland Clinic as I felt my instincts I developed in training served me well. Can’t wait to go back in the future!

Vipan Nikore MD, MBA, PGY-2 CCF Internal Medicine

Chincha - Day 6

June 26, 2012

We started off this week with a tour of Chincha given by one of the nurses at the clinic. An excellent tour guide, she truly made us feel like we were seeing the city--open markets, lunch at a mom and pop restaurant, wine tasting, and visiting the home of the patron saint of Chincha. 

Monday, however, marked the start of another clinic week. We are running with a diminished crew, as many of our friends--physicians and students alike--left on Saturday. (And they are sorely missed!) Luckily, more people from Cleveland came to join the Chincha clinic, allowing us to set up a new station for physical therapy and to continue seeing patients in internal medicine, dermatology, and for metabolic syndrome screening. Despite our diminished numbers, we still had a multitude of patients. One of our most popular stations, eyeglasses and vision screening, saw 65 people today, which is the average for that station.

Most of the cases that I’ve seen in Chincha are what you would expect in every outpatient clinic--upper respiratory infection, gastritis, back pain, etc. A few cases have truly stuck out to me because they are so preventable. One toddler was diagnosed with possible cretinism due to hypothyroidism that could have been reversed if she had been screened at birth. Another woman appeared with a mass in her neck, which was most likely a goiter due to iodine deficiency. In addition to these cases, we also found it difficult to prescribe medications since we were unsure of what was available in the other pharmacies in Chincha.

I spent Monday working with a Peruvian pediatrician, who had been practicing for more than 40 years. She was easy-going with her patients and understood cultural practices that helped her to establish rapport with the parents. For example, she emphasized to me that patients in Peru expected a prescription even if it was just for a viral URI and she would occasionally prescribe Paracetemol (Tylenol) or even antibiotics to pacify the parents. She also knew that Peruvian mothers would often apply their saliva to a ganglion cyst, a remedy that often made the problem worse. A strong believer in the mind-body connection, she advised parents to reduce stress in their children’s lives. Calling herself “medicina antigua,” she preferred to mix Peruvian beliefs with modern medicine. Although not necessarily adhering to current treatment guidelines, this made her more effective at building rapport with the parents and watching out for the well-being of her patients. 

And she truly does care for her patients--this is a belief that everyone at the clinic shares. One physician takes the time to converse with each one, asking about their jobs, how much they earn (28 soles for an entire day of work?!), and comments familiarly that they need to lose weight. Some of the nurses will point out when patients are especially poor, hinting that I should treat them particularly well. Another physician paid for a patient’s biopsy herself so that the patient would be able to obtain a diagnosis. Patients reciprocate by ending appointments with a hug and a kiss on the cheek. It’s these gestures that render the Chincha clinic a community.

Cleveland pride!! (Spelling CWRU in front of clinic)

Sandy Sun, MS3 CCLCM

Sacred Valley - Day 20

June 25, 2012

Hola! Welcome to the final week of this PHOP adventure. I am the resident pharmacist, not really…but I have been working with the ‘farmacia’ for the past week and will be heading up the efforts there this week as well. Truth be told, I am an Emergency Department nurse at University Hospitals in Cleveland and when I applied to come to Peru for this project, I never thought it would lead me to running the pharmacy! Even after receiving the endearing email request about how I would be a ‘perfect fit’ and other flatteries, I still found myself thinking, “Pharmacy, really?!” But with an open mind and a desire to be an integral team member, I took the compliments in stride, inflated my ego and accepted the challenge. J

While I want to update everyone on the pharmacy contributions, I first would like to comment on a few generalities about the trip overall. The last week and thus far the beginning of this week has been an absolutely humbling and enjoyable journey. What I found from the moment I arrived can be summed up in one very simple, yet meaningful word: camaraderie. I am certain I could list a multitude of other adjectives, but this experience truly transcends words. It is one of those, “You just had to be here” kind of encounters. I have had the pleasure of getting to know some phenomenal human beings who will one day soon become even better doctors. We have been up and down mountains together, dodged bulls, discovered lost villages, and braved the public bus system…all for the sake of providing health care to our patients. Gratitude surrounds us, whether from the patients or from our teammates. Every cog in the wheel has its function and not one more significant than the other. We took an “All for one and one for all” mentality and that is what made all the difference on this trip thus far. I believe this allowed everyone, myself included, to traverse the days with comfort in knowing that someone always had your back and was close by to help, whether it be to translate, to barter at the Mercado, or to encourage you as you climbed up the 10,000^th step towards the peak of a mountain.

Sarah and her team hard at work

As for the pharmacy, we have been a very busy team these past few weeks. Many thanks to those who came in the first 2 weeks for establishing an organized system. While we discussed this in meetings, I was not certain how things would actually play out. Nevertheless, the transition into week 3 and now week 4 has been fairly smooth. Every day we travel with 2 very large suitcases and 1 duffle bag full of medications to provide for our patients on that day. While we cannot possibly have every medication, I feel as though we have been able to find something for everyone’s ailments thus far. It may require more “out of the box thinking” on the part of our medical teams, but they are doing it, both efficiently and well.

We have been able to provide albendazole, an anti-parasitic, to a multitude of children and even some adults. Dry and burnt skin is a big problem down here, and we have been handing out eucerin cream to help with moisture and some SPF sun block as well. We are also seeing a great deal of musculo-skeletal injuries, along with stomach illnesses (viral, GERD, parasites) and urinary tract infections. Antibiotics, acetaminophen and ibuprofen have been widely given. It’s unbelievably enlightening to see the appreciation on our Peruvian patients’ faces when we hand them a toothbrush, eucerin lotion, and 20 ibuprofen…not something that would likely be as well received in the states, yet means a world of difference to these people. Having physical therapy, glasses and dental/hand washing education as alternate treatment options have been wonderful tools as well. If next year’s team is half as prepared as we were, all will be well.

Monday's clinic lines

As I wrap this up, I will admit only once that my experience is the pharmacy has been much better than I anticipated. J It was busy, like an ER. I had a great viewpoint of all the other stations, even was able to step away to take pictures. I was the last check and got to see everyone else’s work before me. And best of all, I was allowed to hone in on some of my more ‘type A’ personality traits, like organizing and directing. A win/win for all! Every trip I have taken such as this one has been a life changing experience and this one is no less moving. Thank you for the opportunity and if you are reading this blog and have never been on a journey such as this one, you’re missing out! See you next year!

Sarah O. Strong, RN

University Hospitals, Cleveland OH

Sacred Valley - Another Weekend Adventure

While I want to update everyone on the pharmacy contributions, I June 24, 2012

After another work-filled week in the mobile PHOP clinics in the Sacred Valley, the PHOP crew set out again for Machu Picchu. Though a group of PHOPers had gone to this world wonder earlier in the trip, a new group set out to tackle these Incan ruins for themselves. Following a 4:30 am wake up call and a 5:45 am bus to the entrance to the Incan site, we arrived at the ancient ruins. We were quickly treated to a cloud covered and mystic ancient Incan city before beginning our hiking adventures. 

PHOP Group at Machu Picchu in the Morning as the Clouds break above the ruins but still cover the surrounding mountains. 

A group of us began the hike to the peak of Huayna Picchu at 7:00 am, summiting this exquisitely perilous mountain peak by 8:30 am. This summit afforded sensational bird’s eye views of Machu Picchu and the surrounding mountainous valley as the sun began to break through the clouds. Deciding that this short but demanding hike was not enough to satisfy our outdoor desires, we headed out towards the Gran Caverna, an Incan made cave that ended up being 2 hours from the peak of Huayna Picchu. We reached the impressive site, greatly isolated from the masses of tourists descending on Machu Picchu for the day, and enjoyed our one private Incan ruin. After making the 2.5 hour trek back to Machu Picchu (after which our hiking appetite was most definitely satisfied), we surveyed the ancient Incan city. We visited the important sites, including the Temple of the Sun, Intihuana, Temple of the Three Windows, the Ceremonial rock that mirrors the landscape (my personal favorite), the condor, fountains and many more. Taking a break from these impressive sites, we settled near the Guard House to take in another spectacular view of a sun soaked Machu Picchu. After touring these sites several more times, climbing hundreds of stairs and spending up to 10 hours in this ancient ruin, the group then descended to Aguas Calientes for a full meal and a well deserved nights rest.

Birds Eye View of Machu Picchu from the summit of Huayna Picchu. 

PHOP group members standing in front of the Ceremonial Rock, that mirrors the landscape in the background (unfortunately blocked out by the cloud cover)

This trip was particularly special for me since I had taken several courses concerning Pre-Colonial Latin American Societies as part of my studies at the University of Michigan. The Incan period of Peruvian history was a headliner topic of these courses and we had spent a good deal of time diving into the history and significance of Machu Picchu. It was surreal to survey the same ruins that had seemed worlds away during discussion sections just 2 short years earlier. I was even able to remember some of the details from these classes, acting as an impromptu tour guide for our group, saving us some precious Peruvian Soles! In all, this visit was an incredible way to end my first week in Peru and I am grateful to have spent it with a wonderful group of people.  

Our adventure filled weekend, however, did not end with Machu Picchu as our group decided to forgo a restful afternoon for a trip to the famous open air craft market in the city of Pisac. This market was a fantastic opportunity view and purchase true Peruvian crafts for ourselves and our families, while employing our best bargaining skills. 

A taste of the Famous Open Air Market at Pisac. 

Following the market purchases, we returned to the hotel to welcome our new members, many of which are coming from the Stony Brook University Medical School. This week is the forth and final week for the Cleveland participants in the PHOP program, and promises to provide exciting progress and conclusion to our many on going clinical and non-clinical projects.  

Saludos

- Stuart

MS2, Cleveland Clinic Lerner College of Medicine

Sacred Valley - Day 18

June 22, 2012

I am not sure if it’s the remembrance that makes certain moments stand out in my memory, or if they were truly singular when they occurred. Either way, I will always remember the moment that the cries of a girl from the waiting room of the Lamay Puesta de Salud (health center) caught my attention as I was finishing updating another patient’s chart. Finding myself without a patient, I went looking for the source of the sound and received the intake form from the PHOP members working triage. This three year old girl presented to the clinic because of a new onset of nocturnal nosebleeds for the past month. Clinging to the limited knowledge of a first year medical student, I determined that I would examine her lymph nodes in the physical exam. By the time I met my young patient she had been crying for ten consecutive minute. Like many of our patients, she was dressed up to see the doctors in the clinic. Her eyes were full of tears and deeply brown-green. She was inconsolable, so I lead her and her mother into an unused room in the clinic to see if she would calm down away from the busy clinic. It took me a few minutes of playing and telling her that she had “los ojos bonito” to calm her to the point where I could begin addressing her medical problems. I learned through patient questioning that she also had a 1mo history of anemia and had had a “gripe” (flu) the week before. My physical examination revealed bilateral lymphadenopathy (swollen lymph nodes) but otherwise was uneventful. Upon presenting the case to Dr. Chris Stryker, our pediatrician for the week, we agreed that the combination of swollen lymph nodes, anemia, and new-onset bleeding was probably just a reaction of tiny nostrils to the dry mountain air. However, we also both knew that this triad of symptoms could be the harbingers of a much more serious ailment; childhood leukemia.

Dr. Stryker examining a patient

In the United States, the process from this point would be elementary. A complete blood count (CBC) would be ordered to address the possibility of an over-proliferation of a specific lineage of white blood cell and a normal result would rule out the possibility of a liquid tumor. Sophisticated machines would line blood cells up and force them single-file past a laser, which would help us identify their individual characters and rule out the devastating diagnosis of childhood cancer. However, here in the Sacred Valley of Peru, this kind of CBC is not available without traveling several hours to the nearest large hospital in Cusco. In any of the other clinics we’d seen this week, we would have been unable to do anything but refer this patient to the clinic in Cusco.

Luckily for my tiny friend, the Puesta de Salud in Lamay has been working with our organization for several years at this point. Before we were called the Peru Health Outreach Project, we were known as the Lamay Clinic because our medical outreach focused on this town within the Sacred Valley. Our relationship with the Puesta has been fruitful for both parties, and has allowed our group to grow as well as nurturing the growth of the Puesta. One of our larger donations was that of a laboratory microscope capable of assessing hematological samples. Twenty minutes after walking my patient to the laboratory, the technician who works full time on the microscope was able to draw her blood, prepare a simple blood smear, and manually count the blood cells on the slide to acquire a basic CBC. Having worked with hematologic histology in the past, I asked to also assess the slide and was able to confirm that my patient's blood was normal.  I instructed her on how to safely make a saline nasal wash from sterilized water and table salt and our pharmacy gave her mother a rubber nasal rinse bulb to help solve her issue with nosebleeds. Finally, we gave her vitamins to last the next month.

Will with his 3 year old patient

If our organization did not have a presence in the Sacred Valley, my tiny patient would have had to spend a whole day traveling to and from Cusco to be assessed for a disorder which she luckily did not have. Our efforts have made it possible for the Lamay Puesta to provide essential laboratory services to the people of our beloved region year round. This patient stands out in my mind because she shows how much of an impact we can have on the lives of these patients, because I felt that I contributed to her care in a concrete and meaningful way, and because she would only stop crying for a strange medical student from far away. My time here in Peru has been filled with patients who have made an impact on me for many reasons, but I wanted to share this patient with our community because her story exemplifies the impact of our Project and the connection which we feel with the people of Peru.

Will Tierney

Second Year Medical Student

Cleveland Clinic Lerner College of Medicine

Financial Coordinator - PHOP 2012MS2,