World Tour: Peru Trip
As I was walking up the winding trail to the Sun Gate at Machu Picchu, several thoughts were percolating at about the same time. When was the last time I suffered a heat stroke? I foolishly went to this Lost City of the Incas without a water bottle. Fortunately, two of my great colleagues brought an extra bottle, and I had drunk half of it with my lunch... which they had also graciously provided. This reminded me of an age old wilderness survival question. If you are asked how important a cooking pot is while stranded in the Arctic, never underestimate the importance of being able to boil snow (quick shout out to Ken on this one).
I also recalled the fantastic week that I had spent in the Sacred Valley region of Peru. Working with a group of ambitious, adventurous, and benevolent staff, medical students, and their relatives at a clinic in the small, rural town of Lamay is an experience that I will always remember. Also, the hospitality and service shown to us by the staff and manager, Edwin González Muñiz, at our hotel, the LaQuinta Eco-Hotel, was second to none. I kept on thinking that filling a bottle with the chilled, luscious agua from the water cooler in our dining hall might have prevented some heat exhaustion.
After walking for 40 minutes up the trail in the late day sun, my thoughts started turning towards the meals I had in Urubamba, the town we stayed at while in Peru. The name Urubamba is a Spanish alteration from a Quechua word for good farmland, not flat land of spiders as noted on Wikipedia, yet another reason not to trust everything off of there.
And without further ado, my mind started thinking of Urubamba's finest meats and cheeses. This wasn’t an exaggeration by the way, since the best way to find vegetables in their diet was on a veggie mix pizza (more on this later). Otherwise, this land seemed to be raised on your typical meat and potatoes diet.
Dateline: 29/6/09, a Monday… yes, in my delirious state, I started utilizing the non-American way of dating. After spending 8 hours in an airplane and 8 hours on lay-over in Atlanta and Lima, it was time to head into town for some authentic food. Our first stop was a quaint restaurant called Sol de Mayo off of the Pintacha Square. Our group of fourteen commandeered a table on the second floor and after perusing the menu, I knew I was ready for a cultural gustatory delight. A multitude of parrilladas (BBQ or roasted meats), including the highly recommended anticucho de corazon were in order. If you know a little Spanish, you know that this involves eating the heart of some animal, a cow in this case. As luck would have it that day, 3 of us wished to try this dish, and only two servings were available. Now you might consider it lucky not having to eat a cow heart, yet the 3rd person would end up ordering cuy. This famous Latin American delicacy involves roasting one of your childhood companions, a guinea pig. While I greatly enjoyed my cow heart which wasn’t quite as tough as I was imagining (and yes you could see remnants of the valves,) I only ate a little cuy which had the consistency of quail.
The next meal I thought of during my state of semi-consciousness occurred on Thursday, 2/7/09… see, this is getting more confusing. This was the third day in a row I had eaten lomo saltado, a Peruvian concoction of beef strips, onions, tomato, vinegar, soy sauce and since we were in Peru, both rice and French fries. I think this dish would do quite well in the US since it covers the two main food groups: meat and potatoes, maybe consider serving it at a football game or in a bar. I think the lomo saltado at our hotel was the best, despite some good competition from two local restaurants. Maybe the beef was a little more tender, the potatoes a little crunchier with more flavors, or the extra onions. I highly recommend anyone in Peru to try this Latin American staple.
I finally reached the Sun Gate after 50 minutes of hiking up a semi-steep incline. I thought to myself that I needed a minimum of 20 minutes of pictures and recuperation to survive the hike back down to the main city. I thought of all the times I should’ve exercised in the last 9 years, but hadn’t. I realized that jogging 5 minutes, 3 times a week wasn’t going to cut it for all day hiking expeditions. I wondered how Federer was going to do in the French Open final.
Speaking of Federer, I could almost taste the pisco sours from the Greenhouse restaurant the previous night, a Friday. Pisco is a Latin American brandy apparently made from grapes which is then mixed with sweet & sour, egg whites, and a dash of lime. This is quite a tasty drink, almost too easy to drink. Apparently, there has been bickering between Peru and Chile over the last 300 years trying to decide the rightful origins of pisco. So how is Federer involved in this? Well, I won a bet on the Federer vs Haas match, thus I enjoyed a pisco sour as the reward. A nice trivia fact is that Federer won the Stefan Edberg Sportsmanship award from 2004 to 2007. Anyway, another nice menu item at the Greenhouse was their varieties of pizzas. The veggie mix pizza has tons of toppings on a paper thin crust. There were also a meat lovers, Hell's pizza, supreme, double ham and cheese, among many others. The fresh toppings and light crust were a delectable combination, and you could probably eat 3 whole pizzas by yourself easily.
While walking back down the path to Machu Picchu, I asked one of the staff who decided to go on this intrepid march with me if she heard a sound. At first she questioned what I was talking about. A bird? A llama? The wind? Then, she refrained as we both stood still on the trail. And the beating grew louder, louder! Could it be… a VII/VI heart murmur? Surely not, those in the medical field profess, the scale only goes to VI. Then, how could my colleague hear my heart from almost 4 feet away. On a side note, a nice question to ask your cardiology juniors is how high the scale for diastolic murmurs goes. You might be surprised on the percentage that answers correctly.
After taking the bus back to Agua Calientes, the small town at the foot of the mountains nearest Machu Picchu, I enjoyed one of the greatest tasting Gatorades I’d ever had in my life. Nothing beats suffering and deprivation to magnify the taste of a product. Like the double cheeseburger I ate at Wendy’s after being stuck in the rapids of the Guadalupe River in Texas for 12 hours without food. It takes one heck of a burger to beat that one.
Thus, this was the latter part of my trek thru Machu Picchu. For those who haven’t been, I highly recommend it. It definitely deserves to be on the list of 1,000 things to do before you die. Next month’s article will continue my globetrotting to India. Happy eating.
- James Tarbox, MD
miércoles, 22 de julio de 2009
Last Day
Hi Everyone,
We had our last clinic day today, and ended with a wonderful banquet with the mayor and everyone at the municipality building. It was so wonderful!
They gave us two big perigamin (poster looking thing) with all our names, and gave us all a small plate with our names on them! We have yours....we'll try to get them to you somehow :)
We also got a big cake last night for dinner, thanked all the staff at the hotel. it's so strange that the trip is finally coming to an end, but I think we all had a wonderful time here :)
We had a meeting last night reflecting on our experience, what went well and what we could do better next year etc. If you have any inputs, please feel free to e-mail us.
AND, the reunion -- the most recent projected date is sometime early December -- we are having a fundraiser banquet in Cleveland for raising money for women and children shelter. We thought it might be good if we made the reunion at the same time, so you guys can come to both things :) Will let you know the date when we finalize the banquet day.
Although you couldn't be with us on the final days, the great success of this trip was really a culmination of all of your work!!
Muchas gracias a todos!
Abrazos,
Satoko
We had our last clinic day today, and ended with a wonderful banquet with the mayor and everyone at the municipality building. It was so wonderful!
They gave us two big perigamin (poster looking thing) with all our names, and gave us all a small plate with our names on them! We have yours....we'll try to get them to you somehow :)
We also got a big cake last night for dinner, thanked all the staff at the hotel. it's so strange that the trip is finally coming to an end, but I think we all had a wonderful time here :)
We had a meeting last night reflecting on our experience, what went well and what we could do better next year etc. If you have any inputs, please feel free to e-mail us.
AND, the reunion -- the most recent projected date is sometime early December -- we are having a fundraiser banquet in Cleveland for raising money for women and children shelter. We thought it might be good if we made the reunion at the same time, so you guys can come to both things :) Will let you know the date when we finalize the banquet day.
Although you couldn't be with us on the final days, the great success of this trip was really a culmination of all of your work!!
Muchas gracias a todos!
Abrazos,
Satoko
domingo, 19 de julio de 2009
After three weeks:
It’s hard to believe we’re almost done with our time here.
After our first week, the patient volume slowed down at the Lamay clinic, and so we have been able to take some time to do outreach to the smaller communities of the Sacred Valley. Midway through our second week (while climbing up to 13,000+ feet in search of a glacier) we met Yanett, a social worker who coordinates services for many of the rural mountain communities in this area. These are communities without any clinic whatsoever and with infrequent medical care. Dr. Fike and I traveled with her to Matinga, an adobe village about 40 minutes from Lamay. This Tuesday, half our group will return and run a health fair in the village school.
We’ve been able to do outreach through the Lamay Clinic itself: on Monday I went with Dr. Greenhouse and two other students (Matt Weiss from Dartmouth and Kuba Tatka from Stonybrook) up to another community. In theory, the children we saw are seen every month by a team from Lamay; however, without insurance their medications are not covered, so our presence was pretty helpful – as we were able to either provide or pay for the medications they needed. Mostly what they need is nutrition: all but two of the 14 children we saw are lagging behind on their weight-for-age and weight-for-height curves. After some discussion, we decided to give them all the antiparasitic albendazole, which covers most of the worms in this part of the world, including ascaris, which many of the kids (and adults) we’ve seen at clinic have had before. It’s possible that none of the kids in this group had ascaris, and that their malnutrition is just a lack of protein and calories, but they’re left alone frequently while their mothers are working, and, like children everywhere, they get into what’s around. (Here, what’s around is ascaris).
On Thursday the entire group went up to Pampallacta to run a clinic for the town’s adults. When I say “up” I mean it: on Monday we went up the mountains in the back of the tiny Lamay ambulance, whose rapid climb up the narrow switchbacks left the four of us in back alternately nauseated and terrified (when you can’t see the road out the window, the drop down looks even farther). On Thursday we climbed up from the roughly 9,500 feet of the Sacred Valley floor to 12,700. Here too we used a school for exam rooms (one for gynecology, two for general medicine, one for meds and supplies), and Rachel, who sat outside and did intake, got a sunburn and froze at the same time. Pampallacta is removed from the relatively more prosperous and modern towns of the valley floor, and it had been years since many of our patients had been to a doctor.
As in Lamay, gastritis and low back pain were the predominant complaints, but we were able to do gynecologic exams and cervical cancer screening (with acetic acid) for about twenty women. We diagnosed a few pregnancies and were able to give out prenatal vitamins. Urine analyses proved tricky, as we had forgotten plastic cups. We used the cimetidine and mobic bottles (conveniently empty due to the above complaints) for specimen containers, and when those ran out we used a plastic bag, which dripped and resulted in a photograph of Satoko and me squatting outside – uphill – while the golden liquid dripped into the dust. It was almost as picturesque as it sounds. She held the bag, I the urine strip. Essentially, this trip has been all about two things: teamwork and flexibility.
Next time: planning for future trips…
-Anna
After our first week, the patient volume slowed down at the Lamay clinic, and so we have been able to take some time to do outreach to the smaller communities of the Sacred Valley. Midway through our second week (while climbing up to 13,000+ feet in search of a glacier) we met Yanett, a social worker who coordinates services for many of the rural mountain communities in this area. These are communities without any clinic whatsoever and with infrequent medical care. Dr. Fike and I traveled with her to Matinga, an adobe village about 40 minutes from Lamay. This Tuesday, half our group will return and run a health fair in the village school.
We’ve been able to do outreach through the Lamay Clinic itself: on Monday I went with Dr. Greenhouse and two other students (Matt Weiss from Dartmouth and Kuba Tatka from Stonybrook) up to another community. In theory, the children we saw are seen every month by a team from Lamay; however, without insurance their medications are not covered, so our presence was pretty helpful – as we were able to either provide or pay for the medications they needed. Mostly what they need is nutrition: all but two of the 14 children we saw are lagging behind on their weight-for-age and weight-for-height curves. After some discussion, we decided to give them all the antiparasitic albendazole, which covers most of the worms in this part of the world, including ascaris, which many of the kids (and adults) we’ve seen at clinic have had before. It’s possible that none of the kids in this group had ascaris, and that their malnutrition is just a lack of protein and calories, but they’re left alone frequently while their mothers are working, and, like children everywhere, they get into what’s around. (Here, what’s around is ascaris).
On Thursday the entire group went up to Pampallacta to run a clinic for the town’s adults. When I say “up” I mean it: on Monday we went up the mountains in the back of the tiny Lamay ambulance, whose rapid climb up the narrow switchbacks left the four of us in back alternately nauseated and terrified (when you can’t see the road out the window, the drop down looks even farther). On Thursday we climbed up from the roughly 9,500 feet of the Sacred Valley floor to 12,700. Here too we used a school for exam rooms (one for gynecology, two for general medicine, one for meds and supplies), and Rachel, who sat outside and did intake, got a sunburn and froze at the same time. Pampallacta is removed from the relatively more prosperous and modern towns of the valley floor, and it had been years since many of our patients had been to a doctor.
As in Lamay, gastritis and low back pain were the predominant complaints, but we were able to do gynecologic exams and cervical cancer screening (with acetic acid) for about twenty women. We diagnosed a few pregnancies and were able to give out prenatal vitamins. Urine analyses proved tricky, as we had forgotten plastic cups. We used the cimetidine and mobic bottles (conveniently empty due to the above complaints) for specimen containers, and when those ran out we used a plastic bag, which dripped and resulted in a photograph of Satoko and me squatting outside – uphill – while the golden liquid dripped into the dust. It was almost as picturesque as it sounds. She held the bag, I the urine strip. Essentially, this trip has been all about two things: teamwork and flexibility.
Next time: planning for future trips…
-Anna
lunes, 6 de julio de 2009
After a week
One week down, and we’ve learned a lot.
Lesson #1: Back pain is a universal complaint. We can give NSAIDs and acetaminophen for the pain, but we can’t take away the farming and harvesting that causes it. We are going to try to find some literature on how to lift things safely (ideally it would be in Spanish, with pictures, as much of our patient population is illiterate). A curious thing to me is that most people say dolor de cintura to describe low back pain (this is most of the back pain), dolor de riñon for pain which is slightly higher, and dolor de espalda for the thoracic spine and up. Cintura is waist, riñon is kidney, and espalda is back. We’ve had at least one patient who was correct when he said that his kidney was hurting him.
Lesson # 2: We’ve seen leishmaniasis – both the cutaneous lesion as well as the protozoa themselves under the microscope.
Lesson #3 takes the form of Intro to Quechua. Fortunately, most of our patients speak Spanish; the Quechua speakers can come in waves, which slows things down, because we only have a few translators. In a lamentable parallel to Spanglish, many of the words sound identical to Spanish and are clearly new additions to the language – but the rest cannot be deduced. We each seem to have picked up a word or so. Nanasunkin is mine (a grammatically incorrect way of asking about pain.)
Lesson #4: logistics. On Saturday we combined tourism with volunteerism and went to Cusco to buy more medicines. We hadn’t brought, for instance, children’s multivitamins or antipyretics, both of which have been in high demand. The pharmacy had no chewable vitamins, but we were able to get the antipyretics. In general, we had considerable trouble finding the medicines we wanted: the pharmacy staff did not appear to be pharmacists. This observation was based on the fact that when we asked if there was anything in the same class as metoprolol and atenolol, the answer was no; we spotted propanolol on the shelves a little while later. There were also no Tums, which we found suspect. (Metoprolol – no; Tums – no; Viagra – yes, lots).
The general clinic flow has gone through a few iterations already and will go through another today: we are balancing the needs of the individual patients, the needs of the community at large, and the educational needs of our students and staff. All in all, it’s been a great week, and we are excited about the rest of our time here!
~Anna
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