Post-Trip Reflections

June 28, 2012

Back home seeing patients at Cleveland Clinic, I’m reflecting on my Peru trip and comparing differences in treating patients in the developing and developed world. Chronic disease management stands out as a major difference. 

Chronic diseases have become much more prevalent in the developing world compared to decades ago when infectious diseases dominated health problems.  Many of the Peruvian locals had not seen a doctor in ages and developed chronic medical problems. As an internal medicine physician I’m required to manage such chronic conditions, however, managing chronic disease is a challenge when you’re not assured to have adequate follow up. Several patients come in with diabetes, hypertension, hyperthyroidism, etc, but the treating these conditions appropriately requires continuity. Medications often need to be titrated, and side effects need to be monitored.  For example, a patient comes in with a BP slightly high of 154/90 but asymptomatic. I know this likely needs to be treated but my concern is starting someone on a blood pressure medicine without follow up. What if they are equisitely sensitive to the anti-hypertensive causing hypotension and symptoms of light headedness? One lady I saw had epigastric burning suspicious of peptic ulcer disease, but after further questioning it seemed to be associated with exercise and became concerned that this may be an atypical presentation of angina cardiac chest pain. At the very least I would like to start this lady on an aspirin, however, what if the aspirin triggers a life threatening GI bleed from peptic ulcer disease? I’d be causing more harm than good. The bottom line is that people need a primary care doctor, and primary care requires follow up – which outsiders simply cant provide during a short trip. I foresee many opportunities to solve this problem, particularly through technology and as well as by capacity building of the local community through various community driven entrepreneurial structures.

Despite the challenges in chronic disease management, I can say with certainty that the PHOP group helped hundreds of people. Treating acute complaints and infectious diseases, referring emergencies, teaching physical therapy for back exercises, restoring eyesight with glasses, giving out toothbrushes, shoes, sunglasses, and the list goes on.  We appreciated them welcoming us with open arms, and the Peruvian people genuinely appreciated our efforts (except the one child that kicked Travis, our Friends NE rep, in the “private” parts!). Whether it is their expression as you treat them, witnessing a poor village in the Andean Valley going out of their way to cook lamb for us and naming their new health center after us, or a patient making chocolate bean dip for us, they clearly appreciated our help. And it is this appreciation from the Peruvian locals that made the mission especially rewarding. 

Vipan Nikore MD, MBA
PGY-2, Cleveland Clinic Internal Medicine Residency Program

Chincha Recap

Under the auspices of the Peruvian American Medical Society, Chincha, a small city 3hrs from Lima, was the new and additional site for our project this year. Street side rubble and empty lots continue to be grim reminders that this city was near devastated by an earthquake in 2007. Several of our patients lived in ‘homes’ with straw walls and no roof, making respiratory illnesses a common complaint.

Devastation left behind from the earthquake

At this clinic, we had the opportunity to work side by side with several specialists and volunteers from St Louis, Miami and Chicago. Besides seeing adult and pediatric patients, the students also got the unique chance to work with specialists in Cardiology, Gastroenterology, Dermatology, OB and Endocrinology in an underserved setting! It was amazing that our newly diagnosed patient with hypothyroidism could get an Endocrine ‘consult’ right way (although the Endocrinologist did confess she had never seen such severity of symptoms) or a pediatric patient with severe sleep apnea will get his surgery for free next month at the nearly hospital. Our students were amazing; I heard it over and over again from all the specialists they worked with-these docs want to time their visit with our visit next year to work with them some more! Karen Stary, our star therapist established a PT department in the short time she was there and worked with a local carpenter to make splints for patients who otherwise could not have afforded it. We screened for metabolic syndrome, provided dietary counsel, visited orphanages and schools to discuss dental hygiene, safety and domestic violence, taught CPR to more than 100 individuals, distributed hundreds of eyeglasses… a little accomplished, a lot more remaining!

Students enjoying a didactic session

All these little stories are gratifying and humbling at the same time- the mother who on the last day told me that she would be waiting for our return next year, the local nursing students who shyly took pictures with us, the hugs from our patients, the camaraderie built in the short time with other doctors and volunteers with a common purpose... we are rolling up our sleeves and looking forward to returning next year a little accomplished, a lot more remaining!

Sangeeta Krishna, MD

Cleveland Clinic Children’s Hospital

PHOP Director

Sacred Valley - Day 25

June 29, 2012

Today we returned to Coya. We set up at the municipal building just as we did in week two. Unbeknownst to us, today was the Day of St. Peter so everything was closed. We were able to get someone to open up the building and we set up the clinic. We had a lot of interesting patients and my last patient of the day, and of the trip, was an elderly woman who had vision difficulties. I ended up diagnosing her with severe hypertension, a pterygium that was growing over her pupil, and a suspicious mass growing over her teeth. None of these would have been seen had we not been there to provide care.

Patients waiting to be seen

And done!!  

Today's clinic completed our 4 week mission to ease the medical burden of our friends and patients in the Sacred Valley of Peru. By all measures we consider this experience a great success. The final numbers need to tallied and medicines counted, but it is safe to say that we have provided direct care to over 2500 men, women and children in need. Having personally seen several hundred myself, I have been touched the great need and the great generosity of these people. For example, last week we were in a small town named Quihuay. At the end of the day, I was asked by a lady to see her grandmother who was sick, could not walk, and could not hear. Tiffany Moadel and I trecked up to the home and found our patient sitting on the dirt, sorting corn. She had been in this condition for years and had been declining. While it was believed that she could still stand with help she no longer had the strength to walk. To move she crawled on all fours and rarely left her home. Throughout all of this she still trudged along with her same routine for nearly a decade. In the moment there was little we could do, but I remembered that we had a couple of walkers at the hotel. While leaving the village gave us a feast of quinoa soup that was delicious. The next day while we had clinic in Lamay, I continued on the bus and dropped the walker off at a nearby health post. While I couldn't see her use the walker, the excitement they had knowing that we were bringing a means to make her mobile again made my day. Hopefully the gift will extend her life and increase her independence.

This trip has been enjoyable, and rewarding. I look forward to continuing on similar trips throughout my career and afterwards.

Clark Madsen, CCLCM MS5

Chincha - Day 10

June 29, 2012 The week spent in the PAMS (Peruvian American Medical Society) Clinic in Chincha was totally different from the clinics run in the Sacred Valley. Besides the urban vs rural aspect, the patients came in for more complicated problems for the most part, and lab and radiology backup was available and frequently expected. Many of the patients had previous evaluations, although little information from these was available to us at the time of the visit. Medicines obtained by prescription or from the pharmacist directly (including steroids) were frequently not identifyable because of Peruvian brand names used. That said, the level of medicine practiced in this clinic was higher than that available in the Sacred Valley, where minimal lab and radiology were available. Interestingly, the electronic medical record we employ in the valley would revolutionize the clinic in the city. The staff at the PAMS clinic was very helpful and friendly. I worked with Coco (ask me sometime how she got her nickname), who was awesome in interpreting and providing support in setting up patients. She is a real asset to the clinic. The facilities around Chincha were vastly different from the more austere area around the Sacred Valley. The market here was bustling and crowded, much different than that of Pisac, which was more geared toward the tourists.  The bustling PAMS clinic waiting room I personally preferred the bucolic setting of Urubamba (Sacred Valley) with a slower pace of life and practice of medicine, with opportunities to walk the countryside. I hope by this time that everyone has returned safely, or is traveling safely enroute home. Looking forward to next year in Peru. Bill FIke, CCF Internal Medicine

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