Iquitos; Tout Fini

Coming to Iquitos was a good way to end things.  We took the final exam on a Monday so the last week was focused on reviewing and tying up loose ends, discussing case histories, touring an entomology/malaria research center and seeing patients.  The pace was less intense, allowing for a little touring each day during siesta hour.

Although it didn’t seem all that hot getting off the plane, within minutes I was drenched with sweat.  This is the jungle and it is summer here.  One of my classmates said that it smelled like Bangkok.  Although I have never been to SE Asia, it certainly fulfilled my image.  There were motokarts (the frontend of a motorcycle grafted onto a rickshaw frame) chaotically whizzing around, lush and exotic greenery and plenty of people.  Iquitos, a city with more than 500,000 inhabitants, is bounded by the Amazon, Nanay and Itaya rivers.  It is purported to be the largest city in the world not connected to the outside world by a road.  Kind of like the Sitka, AK, of the southern hemisphere.  The 100km (60 mi) long road to a small settlement called Nauta does not count. If you want to visit, you need to arive either by water or air.  It is a hub for resupply for mineral exploration so it includes all of the expected trappings of the drug and flesh trades.  My vision of the jungle in SA is prejudiced by the movie Fitzcaraldo.  In fact, some of the scenes were filmed in the floating community of Belen, a part of Iquitos.  Unfortunately, I never escaped far enough away to see any really isolated spots. 

The hospitals and clinical settings were the most primitive of the course.  Lab testing and radiographic imaging were  limited.  There were also fewer medications to choose from.  People are also poorer here so even those modalities that were available were used less often because of personal financial constraints.  We were more likely to make a diagnosis solely on clinical grounds here than at any other place that we visited.  This was also the only place where I was approached by family members, either for money for medication or some personal intervention on behalf of a family member.  (I am certain that it was the white coat, scrubs and my gray-haired, gringo look.)  In one instance, several of my classmates arranged to buy some medications for a very sick kid. 

We saw several cases of significant starvation.  The terms kwashiorkor and marasmus have been supplanted by levels of starvation that reflect the presence or absence of edema (swelling).  Chronicity, energy supplies/diet, the relationship to recent infections and other factors play into the clinical manifestations.  We no longer believe that severe starvation (with edema) is caused by a protein deficient diet.  In turn, the fix is not dependent on and the condition can be made worse by a high protein one.  Two of the kids we saw were moribund.  It was a sobering experience, especially seeing that these kids were not doing well for potentially fixable problems despite being in the hospital.  It was the most helpless that I felt during my stay in Peru.  I am not naïve.  I realize that the starvation that we saw occurs on a much larger scale other places in the world. 

So, was this course really worth it?  Yes, without a doubt

1.  The medicine is interesting and I believe relevant both for WMA and my medical work here in the US as well as abroad.  We are seeing more immigrants from tropical areas and many of them take trips home.
2. Being a student again allowed me to see and experience the educational process from a different prospect.  That it was fairly intense only heightened my awareness.
3. It is no surprise that I enjoy a challenge and Gorgas was that.  It was a challenge to be a student who is 62 yo studying with a younger and better informed crowd, in a different country in a field where I was woefully unprepared.  I hope that I can continue to read, learn and hone my general conceptualization and practical skills.
4. It turns out that there are other learning opportunities in Peru, Africa and SE Asia.  I look forward to more study and practical application. 

This blog turned out to be fun for me.  I will work to continue it when I travel and will express my opinion or relate an experience now and again in between trips.

Portrait of a student as an old(er) man

Although my credentials intimate higher educational success, school has never been particularly easy for me. When I didn’t work hard, it was not because I didn’t have to. It was usually because I was bored or did not care. Mostly, traditional education is rote, based on reading and listening for regurgitation in some fashion at a later date. I am not particularly good at any of those. I may read a lot but if the text is content heavy, I generally only retain an abstract of it. I learn by seeing and doing and figuring things out for myself.

In formal education information sticks best when it is introduced and fleshed out in a lecture and/or through reading and then is reinforced by demonstration and practice. WMA’s conceptual-based, hands-on approach is the gravity that pulled me in. So I knew that lots of reading and lectures laden with new content would be a major challenge for me here at Gorgas. On the whole, the faculty has done an admirable job mixing the formats so that even with the volume of information covered, they did all they could to make learning possible.

The impact that my age (61 and change) had on my ability to learn turned out to be more revealing and interesting.  A lot has changed in the 35 years since I graduated from medical school.  My hearing has suffered declines no thanks to motorcycles, chainsaws and jet travel.  Although hearing has not been a big issue at work in the ED, more and more I find myself asking students to repeat themselves in class.  My near-vision has declined as well.  Vanity notwithstanding, I have come to magnifiers later than most people similarly afflicted. Prior to the course, I used them mostly for suturing and, after a bad day, to read a book at bedtime.    So, in anticipation of prodigious amounts of reading and the inevitable back-and-forth in the classroom, I had my eyes checked, bought a pair of prescription magnifiers and committed myself to eschew my usual backbench seat for one right up front.

Desptie these efforts, my vision and hearing losses were constant reminders that I am no longer 27. I fumbled with the glasses while my attention shifted between the screen and my notes. (I tried bifocals once and they made me fell nauseous.) I missed more than a few concepts when an instructor turned away from me or spoke in a muted volume, the end of a thought dissolving as though it was unimportant. I even answered more than one question with an “I don’t know” not because I didn’t but because I didn’t want to ask someone to repeat something for a third time because I just couldn’t get past an accent or a soft voice. I was just swapping one potential embarrassment for another.

All of this made me aware of  how isolated one can feel. I don’t mind sitting or standing alone in a crowd while others socialize around me, but this was different. As good as the staff was, not once did anyone ask if any of us had any disabilities or special needs. There were a couple of times I (and a couple of others) asked someone to speak up. The person did, for a couple of minutes.  It was surprising how infrequently the lecturers repeated questions before answering them. I am not trying to be particularly critical of the staff. This is nothing unique in an educational environment, especially with a young and highly intelligent crowd; our class was mostly both. But if an educator like me is reluctant to speak up, what about so many others?

This is a reminder to me, if I needed one, to be more aware of who is in class, or next to me on a plane. People don’t need to be beaten up over the issue as much as reminded that our inner workings are not identical.  Whether it has to do with sensory perception, brain organization, or locomotion, we are different enough to merit flexibility. One of my prior students, a guy that I have worked with in a variety of contexts reminded me once that it is not a divide between able versus disabled but a spectrum, degrees of ability. He liked to refer to me as temporarily able. Not anymore.

El Valle Sagrado de los Incas

As I suggested previously, there is a lot to see in and around Cusco. This place is bathed in Inca history and culture.

One afternoon between morning rounds and the afternoon lectures, a couple of us took a cab to Saqsayhuaman. This site is located about 15 minutes above and to the north of Cusco. From the top you get a wonderful view of city. The site itself is actually pre-Inca. The Incas added some of their own touches and the Spanish ruined large parts of it, pilfering stone to build churches in Cusco. Starting there and through our tour of El Valle Sagrado de los Incas, it became clear to me how little people know about what, how and why the Incas did what they did.  The guides that we engaged at Saqsayhuaman and later for a day long trip along the Urubamba River offered up their version. They are justly proud of their heritage and understandably bitter about the European invaders so the spin that they put into their presentations makes sense. I have subsequently read somewhat different explanations on the web. It is always fun to speculate but that is all that it is. I am sucker for modern day efforts to reproduce the tools and technology used in the past, but it is safe to say that our 21st century efforts using hypothesized 15th century technology fall far short of what the Inca people actual accomplished.  These speculators were either dead wrong or their clumsy efforts further underscore how masterful Inca engineers and builders really were.  Today’s pre-stressed concrete and glass structures, erected with complex machinery pale in comparison, if not in scale then at least in grandeur and mystery. Further, it looks like the Incas did not change the environment to accommodate the structure like we do. Everything that I saw seemed to fit in with the topography that was (and is) there. Maybe they had no other choice because they lacked heavy construction machinery that could destroy and then rehabilitate the environment (unless you still believe that this was all the work of aliens). These were and are remarkable people.

I was really surprised at how verdant the rolling hills outside of Cusco are. It reminded me of the farm country along the Mohawk River Valley and on south of there in upstate NY. There were patchworks of various shades of green dotted with the colorful flower blossoms of potato, corn, quinoa and a wide variety of other vegetables. Heading up the valley, the fields give way to more steep landscape that is terraced for planting. This style of construction and agriculture is the sine qua non for an Inca community. It is pretty remarkable that in many locations these areas are still being cultivated, the structural integrity still intact. The magnitude and breadth of the terraces is particularly evident at Pisac where it is possible to get a really panoramic view of them snaking around the irregular contour and marching up the slopes, covering a vast area.

Further up the valley we visited Ollantaytambo. Although not as famous or as isolated as Machu Picchu, it is nonetheless spectacular. You have to climb a steep stairway of large stones to gain access to the terraces and the upper reaches with their buildings. Horses could not have climbed them and foot soldiers would have struggled, their clanking armor providing an alarm for awaiting adversaries. I won’t venture a guess as to the height but it is a very impressive exposure, dizzying actually, when you walk along the edge. Some large stones lying around randomly on one of the flat areas at the upper reaches provided evidence that the site was never finished but that their plans were ambitious. Some had the remains of elaborate three-dimensional surface carvings, most of which had been defaced by the Spaniards. You can also see where the large stones came from – over a mountain, along a river and then up a graded earth-ramp to the top. The view from the top to the old town below and the other side are spectacular.

Chinchero was our last stop. Even though we missed their famous Sunday Inca market we did get what was billed as a private demonstration session showing how they produce the fabrics sold at the market. The most interesting part was how they made dyes from natural products by mixing mostly plant-based powders in water. By using more than one dye on consecutive dips almost magically they transformed one color into another. They even crushed dead beetles to produce a vibrant red used for makeup.

This is only part of what I saw and certainly not much of a detailed description. There are plenty of references on the web and I did take a few picts if you want to see more.  Read 1491 to get one revisionist’s view. Machu Picchu seems to be THE destination but there is more than enough to see just in the Valley for a lot less money.

My group

One of the highlights of the course has been the clinical rounds.  The concept and execution represents a masterwork by the staff.  We saw patients in 3 hospitals in Cusco and Iquitos and 4 in Lima, each representing a unique clinical and social experience.  With a few understandable exceptions, we saw at least 3 new, interesting patients per day.  All the groups got to see all of the interesting patients.   It was a good opportunity to learn about parts of medicine that I have never seen before (unless I have missed it) and learn about healthcare in Peru. 

As I previously mentioned, the class was divided into groups of 5 – 6 people, each constituting a clinical group.  I got to know the people in group #6 the best because we worked together 2+ hours every day.  The patients and rounding attending physicians changed but we always traveled together.  With their permission, let me introduce them.

Paulina, an RN relatively recently graduated from nursing school in British Columbia, is the group member that I admire the most.  I struggled mightily from the start with 30 years of practice backing me up so I cannot imagine what it was like for her.  Every day she was cheery and ready to go.  There were many interesting lesions, radiographs and ultrasound images.  Because she had a nice camera, Paulina became our default photographer, mostly.  She did it unobtrusively and well.  I felt like I was hanging out with one of my daughters.  That is something that I don’t get enough of.   

Esther is doing one year of Internal Medicine before starting Dermatology in Boston.  Tropical Medicine is a gold mine of interesting lesions, some by themselves and some as manifestations of other diseases.  As in clinical practice almost everywhere, most of us are clueless about Derm.  Never mind she hasn’t even started her Derm training yet, when we did not know what we were looking at, we turned to Esther.  She has a wonderful air of confidence – confidence to try, a willingness to expose herself, even when she did not know.  This wasn’t arrogance.  She was just willing to take a shot.  It sounds like she was brought up in a home where it was a given that anyone could do anything.  It shows.  Plus, Esther is always ready for a good laugh even at her own expense.

Jinny is the Pediatrician in our group.   She is a fellow (if a women can be a fellow) northern New Englander from Vermont.  Like me she took a circuitous route to get there but seems to fit the bill of my vision of a Vermonter, albeit transplanted, nicely.  What can you say?  Jinny is smart, compassionate, funny, insightful, and a pleasure to work with.  She managed to do this course with her 14 yo son living with her for a few weeks before her husband came to join them.  That fact alone merits special commendation for her.  The 14 yo is a good kid but he is 14 yo.  I found it hard enough by myself; I could not have been Mom to anyone.

Brent comes by way of the Canadian Armed Forces.  He is Family Medicine trained with subspecialty fellowships in Infectious Diseases and Critical Care Medicine.  Oh, and by the way, he is an aviator (flew fighters and rotor wing) and has worked as an engineer for GM.  This was tough for Brent because he has done 2 tours in Afghanistan, and has another coming up, all while being both a father to 3 young children and a husband.  I didn’t get Brent at first but I think I do now.  He takes his responsibility to care for his guys personally.  In the military you get trained and then are tossed into the frontline, usually in a place vastly different from where the training took place.  The fact that you are alone does not help.  There seems to be an element of immediacy for him about the information offered here because of its practical, day-to-day relevance to his military mission.  Brent is like a bulldog so he grabbed a hold of everything possibly pertinent to this mission until he got it.  I hope his patients appreciate what a smart, compassionate, stand-up guy he is.

Clevy is a wonder.  Her background is also in ID currently finishing her training in the Dominican Republic.  How she knows so much about ID, especially the complicated nuances of HIV/AIDS and Tbc at such a young age is a wonder to me.  When we had opinions we would toss them out (in my case, they were pretty feeble) and then Clevy would put the case together in a convincing and clear way.  I may have learned as much from her as anyone else here.

Although Brian was not part of the group referenced above, I have spent more time with him here than with anyone else.  He was my roommate.  Allow me to digress.  Despite all of the effort to make the move here as seamless as possible, very few of us had places to live prior to our arrival in Lima.  In the context of advice about what to study before the course and warnings about the dangers of not securing a safe cab at the airport, the process of finding a room sounded as though it would be straight forward and simple.  In reality, it was somewhat stressful and confusing.  On an appointed day, we all met at a hotel, were introduced to some real estate agents and then sent out on a bus, en masse, to see the available properties.  Some people were fairly aggressive and latched on to the first places we were shown.  Most of the rest of us were clueless until it became clear that if you didn’t secure a place on the first day, you would have to do it all over again the next day with no guarantee that you would actually find something.  (One of the agents said that she had no other new properties to show the next day.)  Because most of the apartments were for 2, it seemed important to connect with someone to room with, ergo Brian.  Both processes felt like a hybrid between musical chairs and speed dating.  When I approached him, Brian made it clear that he was not a partier.  I wasn’t sure if he was warning me off because he had an antisocial personality or putting me on notice that he would not put up with any crap from me.  As it turned out, it has been a good fit.  We are both more Oscar Madison than Felix Unger.  Both of us are independent, letting each other live and let live.  Most of the time we managed our respective meals separately and kept our own company.  I enjoy his sense of humor and the person that he is.    

Brian is a Peds ID Fellow at the U of AL.  He really cares about kids.  You can see his compassion and his clinical acumen with any of his interactions with kids.  Peds ID is a tertiary hospital sub-specialty.  U of AL has a good ID department so the fact that he is there means that Brian is smart but also that he has research obligations.  Clinical and research are not necessarily compatible.  It will be interesting to see how he sorts this out.