A Week of Rural Medicine in Peru

Last week was one of the best learning experiences I've ever had. Coming to Peru to volunteer and open medical clinics was unlike anything I've done before and I think it really changed the way that I see medicine and patient care. It also gave me a unique perspective about a different culture, helping me realize that there's still so much for me to learn about the world. Peru is very different from any place that I've ever been, and I loved it so much that I can't wait to come back soon!

Saturday, December 15, 2018: Flights, Flights, Flights

After months of anticipation, today's the day I set off on my journey to Peru! I've been so consumed with final exams for the past two weeks that it's been hard to spend any time being excited. Now that it's vacation I'm really excited to go to Peru! This morning I got up and finished packing the rest of my things before leaving for Logan. I actually saw one of my friends at the airport, so it was nice to see a familiar face before leaving. I'm going with a group of students in the PA program at MCPHS to treat patients around the Cusco area. I know a few of them from school, but I'm really excited to get to know everyone a little bit better and have some fun experiences!

When we got to Lima after ten hours of flying, we got our bags quickly and killed some time before our flights to Cusco. It was midnight and I was hoping to get some sleep, but there weren't any chairs in the check-in area of the airport so it was difficult. I ended up sleeping on top of my suitcase for about an hour, but it obviously wasn't very comfortable. My flight to Cusco boarded at 3:30am, so on the way to the gate I stopped for some food. My dinner had consisted of cheez-its and peanut butter M&M's, so the sandwich with sweet potatoes and chicharrons tasted like heaven. I also got papaya, orange, and banana juice and french fries. It was a great but odd early morning pick-me-up.

Today was a relatively uneventful travel day with a short layover in Ft. Lauderdale before landing in Lima. I'll have one more short flight tomorrow morning from Lima to Cusco, our final destination. Flying Spirit airlines was about what I expected with little leg room and money traps seemingly everywhere I turned. This being said, they were the cheapest flights by far so I think it was worth saving a few hundred dollars to sacrifice on comfort! Would I fly Spirit again? Not unless it was significantly cheaper than every other option, but it definitely could have been worse.

Sunday, December 16, 2018: Exploring Urubamba for Our First Day in Peru After the early flight from Lima to Cusco we had five hours to kill before being picked up. We ended up sleeping on hard plastic chairs at the airport (not comfortable to say the least) for some much needed rest. We were all drained from the lack of sleep the night before so it was good to close our eyes even just for a few minutes. We left around 10:30 for Urubamba, the city where we would be staying. It was just over an hour drive, and every second of it was absolutely gorgeous. I was hoping to sleep on the bus ride, but I stayed awake because I didn't want to miss the views! There were mountains everywhere we turned and rolling hills in the valleys below. The best part was all of the colors of the different crops growing everywhere compared to the greens in the mountains. The weather was surprisingly warm at a sunny 60 degrees, and we were at an elevation of 12,000 feet at some points during the drive.

The house was absolutely gorgeous. It was huge with about ten bedrooms, and enough room for almost all of us to stay. They had a beautiful pool and many balconies all looking out at the mountains surrounding the town. Urubamba itself is at just under 9,000 feet of elevation, so I was a little worried about altitude sickness. I had taken Diamox preventatively which worked well. After settling into our rooms, we set out to explore the town a bit before we had our pre-clinic briefing.

Urubamba is a small city with lots of shops and restaurants. Peru is known for having amazing food so I was really excited to try all of the popular places around the town. First we went to lunch at Kaia, a vegetarian restaurant near our house. It was in a beautiful courtyard with a very homey feel. We sat outside under tents which was perfect because the weather was gorgeous. I got a mango and cardamom smoothie and a lentil burger with plantains, sweet potatoes, and pickled veggies. It was delicious. After lunch we walked around for about an hour though the town square and the market. The produce looked so fresh. There was a mix of the typical produce you could buy in a grocery store and exotic fruits, some of which I had never seen before. Then we went back to the house to relax a bit before our briefing from the local doctor. It was beautiful and sunny outside, so a bunch of us lay by the pool and decompressed.

At the briefing the local doctor with whom we would be working came and told us about what we would be doing and the culture in the area. It was interesting to see how different places have very different views on health care so we learned some techniques that would help us care for our patients in the most effective way. We also heard from Ari, one of the PAs that we would be working with who did one of her clinical rotations here when she was at MCPHS. It was really cool to talk to her because she had been in our same program only a few years before and was coming back as a provider now. It was crazy how much she knew only a year after graduating from the program. It was a little nerve-wracking to know how much I would have to learn in the next two years to get to that point, but it was also super encouraging to see how successful she's been since graduating.

After the briefing we went to dinner at a local pizza place and tried pisco sours, a drink native to Peru. They were kind of like a margarita but with pisco, a local liquor, instead of tequila. They also had a foamy egg white topping that was almost reminiscent of meringue. It was really good and kind of reminded me of key lime pie only not as sweet.

After dinner I was completely exhausted and promptly went to bed. It turns out in the previous 48 hours I only had 5 hours of sleep (one of which was laying on top of a suitcase on the floor of the airport). Needless to say I was asleep before my head even hit the pillow. Monday, December 17, 2018: First Day of Clinic! Today was our first day of clinic! We woke up and ate breakfast at the house before driving fifteen minutes to where we were setting up the clinic. Breakfast was a huge spread with eggs, sausage, fresh rolls, cheese, fresh squeezed orange and Peruvian Sauco jam. The jam was probably my favorite part because it reminded me of the Swedish lingonberry jam from my childhood. Everything was homemade by the family hosting us and it was all delicious.

After breakfast we rode in the back of a truck with our medical supplies to a local community center where we set up our clinic. I hadn't realized this earlier but the only equipment we had access to was what we had brought with us. I thought we made d0 surprisingly well with what we had all week. There was a super cute little girl who we played with while we set up the clinic.

I was stationed at intake taking vital signs, so although hectic at times it went pretty smoothly. We saw about 70 patients all day but they came in waves so sometimes I was banging out sets of vitals in under two minutes. I haven't done the whole taking a BP while simultaneously measuring respirations and asking the patient questions type of multitasking in a while, but I got the hang of it after a few patients. After noon it was pretty slow so I played with some other cute kids.

Some of the other students on the trip were with the providers treating patients, so it seemed like they learned a lot. It was kind of nice to be doing vitals because I know that's something I'm good at, but I was looking forward to getting out of my comfort zone a bit and do some more hands-on patient care in the coming days. The hardest part about the whole day was the language barrier. It was really difficult to communicate with the patients who only spoke Spanish or Quechua. This is pathetic to admit, but I took 6 years of Spanish in middle and high school. I should definitely be better at it, and if I had been more diligent about reviewing and learning it earlier it would have been much easier. I really want to take a medical Spanish class at some point, so that's now pretty high on my to-do list after this trip. Back in Boston many of my patients speak Spanish so I feel like it would be a really good thing to have knowledge in.

We closed up the clinic around 5pm and headed back to the house to debrief after our first day. I decided to walk back because, although I had been on my feet all day, I hadn't really moved much and I thought I could use the workout. At the debriefing we chatted about what worked and what could be improved upon for tomorrow. We then left for dinner pretty early and decided to go to Kampu, a Peruvian-Asian fusion restaurant right down the street. This place had probably the best curry I've ever had. We got a bunch of different kinds and it was absolutely delicious. It was the kind of meal that makes both your stomach and your heart full by the end, and we could tell that the chef definitely made all the dishes with love. He came out a few times to talk to us and make sure everything was okay. One common theme that I've noticed is the hospitality of the locals. Everyone has been so welcoming towards us which really made me feel more comfortable being in a place so different from home.

Today was a long and busy day, but overall I think it was pretty successful and I can't wait to see what tomorrow brings! Tuesday, December 18, 2018: Ortho Day with Tom! Today was really great because I feel like I learned so much and got to help a lot of patients. I got to do a lot of patient assessments and some dry needle procedures for muscle pain. The day started off with a huge breakfast per usual and then we were off to clinic. I was stationed with Tom, a sports medicine doctor who practices in Beverly.

We saw a lot of patients with chronic lower back pain because lifting heavy loads is a daily occurrence. Some patients presented with shoulder and knee pain. We treated many patients with dry needle trigger point injections. This is when a needle is inserted into a painful knot in the patient's muscle. It is pulled out and pushed back in repeatedly to relax the muscle and relieve the patient's pain. It's kind of like acupuncture with bigger needles and it actually enters the muscle to relax it. It was really interesting to see how quickly their pain went away after the procedure.

There were lots of children in the clinic today as well. Many of them presented with gastritis, a very common condition in this area. It's often a result of dehydration because a lot of the people in the area only drink one glass of water a day or less. A big part of our job here is patient education, so we told almost everyone we saw that they should drink 7-8 cups of pure water a day. Sometimes patients think that when you say water it means any type of liquid (juice, soda, coffee, etc.) so it was important to specify that they should be drinking pure water.

We saw about 80 patients today and I think the day went a bit more smoothly than yesterday. We all kind of got the hang of how the clinic should flow a little bit better so that was good. The day went by really quickly because we were doing procedures all day and seeing many patients.

After the walk back to the house and the debriefing we went out to dinner at Paca Paca, a pizza place that makes their pizza with quinoa crust. Quinoa is really common in Peru and the pizza was great! After that we went to a bar and ice cream place where we hung out for a little while before going back to the house and turning in for the night.

Today was a long day but it was super interesting doing the trigger point injections and learning more about sports medicine. Tom was an amazing teacher and I felt like I learned a lot from him. I'm also really interested in orthopedics and sports medicine so it was great to get a small taste of it. Wednesday, December 19, 2018: Our Last Day at Clinic in Urubamba This morning we started with our normal huge breakfast and then we walked the 1.5 miles to the clinic. I was stationed with Ari, and I felt like I learned so much working with her today because she had us ask the patient's questions and proceed with the assessments. As I've mentioned, my Spanish isn't great so Ari translated for me which was super helpful. I could understand almost everything that the patients were saying, but I just have word finding issues so she translated my questions to the patients. I feel like I learned how to be much more in depth in my patient assessment because as an EMT our patient assessments are less involved.

We had a lot of cases of lower back pain because a lot of the patients had come down from the mountains where they work in the fields all day. We also got a few more interesting cases. The first was an 83 year old woman with aortic stenosis and a very prominent murmur. She also had mitral prolapse causing heart failure with reduced ejection fraction that we could see on an echocardiogram. In addition she had previously had surgery for her cataracts, but something had gone wrong with the surgery because her pupil was displaced and she couldn't see out of her right eye at all.

We also saw a patient with gallstones that we found with an ultrasound. I had never seen them before so it was really cool to be able to connect her symptoms with a diagnosis that we could see so clearly. The people that came down from the mountains were in better shape than most people I've seen of their ages. It was very obvious that the people of these mountain communities work incredibly hard throughout their lives. Today was also our first taste of the rainy season with pouring rain in the middle of the day for about two hours, the first true storm we had encountered.

We saw about 90 patients today making it a really busy day at the clinic. It was a long day, starting at 8:30 and ending around 5:30, but it was another really rewarding experience even though we were all exhausted by the end of it.

After we walked back to the house and debriefed, Tom and Kathy showed a few of us some phlebotomy skills and let us practice on them. It was really nice of them to teach us and we all succeeded in hitting the veins on our first try. It goes to show again how much they care about helping us be better providers in the future and the type of hands on support and experience we've gained throughout the trip.

Afterwards we went to Paquarina, a restaurant near our house. I went with another student on the trip who was actually an undergrad in her freshman year at MCPHS. She's vegan, and although I thought she would have a hard time finding places where she could find vegan food it was surprisingly easy all week. I got carnitas tacos which were amazing and she got a lentil burger that was also really good. We both got smoothies as well which are surprisingly common at restaurants in the area. After dinner we went back to the house and hung out playing card games for a little while before bed. Today was another really exhausting day, but it was really fun and Ari taught me a lot about treating a patient from start to finish. I wasn't sure how things were going to work coming into this trip because my Spanish isn't great but it actually went really well. This being said I definitely need to work on my Spanish skills for the future!

Thursday, December 20, 2018: New Clinic Location in Huayllabamba Today we went to a new clinic location in Huayllabamba to be more accessible in the rural town. Unfortunately, the space was much smaller than the building we had in Urubamba, so we had to be a little creative in creating the privacy needed for some of the procedures that we do.

I was stationed with Katie and Kathy in their PT/OT clinic. This is really important in these areas because a lot of the patients have to lift heavy things and do manual labor for work. We had many back and leg pain patients so the exercises we gave them were mostly focused on that. It was slow for many parts of the day though because not all of the patients need PT. Katie and Kathy were super nice about letting me step out at certain points to be with the providers.

I've been having some back pain every since I slept on my suitcase in the Lima airport, so Kathy showed me some stretches to help me with that and also gave me advice about the lifting routines I've been doing at the gym. It was nice to have her input!

Other than the PT that I got to do a few minor procedures today. I did a cortisone injection along with a few vitamin B12 injections so that was pretty cool. I also got to perform my first Pap smear so that was exciting. In addition, we saw a woman with an oxygen saturation of 67% (normal is 92-100%), and although the air is thin here because of the altitude it was really concerning. It turns out that she had bilateral pulmonary effusion (fluid in her lungs) and heart failure. It's hard with heart failure patients because the only thing we can really do for them is refer them to a local cardiologist.

Today was our busiest day with over 120 patients. It was great because we got to help so many people, but it was also hectic. After clinic we went to a really nice restaurant, El Huacatay, and had a nice dinner all together. I ate alpaca, one of their most well known dishes, and it was surprisingly good. It was a little bit gamey, almost reminding me of venison, but really yummy. I'm glad I tried it although I was hesitant at first. It was also really nice to have dinner all together after splitting up into small groups the past few nights. We all talked about our favorite and least favorite parts of the trip, and it was great to hear everyone's thoughts. After that we went to our usual bar for a drink and then home where we played cards and hung out before bed. It was my last night with the group so I'm really glad we all got to spend some time together before I left to go backpacking.

Overall, this week was probably one of the most amazing and rewarding experiences of my life. Being in such a beautiful place and helping the community was both fun and humbling at the same time. The people here live so differently than what I've experienced in the states and the other places I've been, so it gave me a really unique perspective. The patients we saw were some of the nicest people I've met in my travels, and I was really touched by their kindness. My Spanish isn't great, but they were so understanding and helpful when I was struggling to figure out what I was trying to say. They also brought us locally grown food while we were in clinic which was so nice of them. They were all so appreciative of the help we were giving them it made the experience very rewarding.

I just want to take a second to thank everyone who donated and helped make this trip possible for me. I couldn't have done it without all of you, and I think that I can speak for everyone that we treated when I say that your donation really made a difference. Thank you all so much for your support!

My favorite aspect of this part of my trip to Peru is all of the friends that I've made on the trip. We started off as a group of 20 random PA students and health care providers, but I think in the past week we all grew pretty close as a result of this trip. I think I can say I've made some really great friends that I'll definitely keep in touch with in the future. They made the trip a lot of fun and it wouldn't have been the same without them!