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.

Medicine in Cusco

 After landing in Cusco (see separate post on Cusco), we were given a couple of hours to get settled before heading off on clinical rounds at Social Security (SS – for the working insured), public, and catholic charity hospitals.  The visits were followed by some case study presentations.  The hospital patients had been scoped out by the Gorgas staff just before our arrival.  They were either newly arrived or people with diagnostic dilemmas. 

This was not Lima.  Although the SS hospital seemed fairly well equipped, it was hard to get a real feel for it because we only saw patients in a clinic-style venue.  The public one was pretty well staffed but it was apparent early on that the resources for evaluation and treatment were not what we had seen in Lima.  This was particularly apparent with the sick kids we saw, 3 with significant and complicated osteomyelitis (bone infection) and one with a serious infectious encephalopathy characterized by fever, confusion, and rigidity.  (No, this time it was not rabies.)  One real surprise was seeing 2 cases of malaria, surprising because malaria is not found above 2000 m (about 6600 ft) in Peru.  Both were locals who had returned from the jungle.  In tropical medicine, the travel history is VERY important. 

The local staff accompanied us on our rounds.  They were polite and open but it was clear that to some degree they were struggling with our presence.  We wanted to understand their limitations and offer what we hoped would be useful insights and suggestions.  But they knew where we were from.  Our curiosity, incredulity, and compassion were not easily hidden and could have been (and probably were) misinterpreted as judgmental.  I know the feeling.

My favorite visit was to a catholic charity hospital.  They provide care for the poor in busy outpatient clinics and in hosptial wards with limited services.  We did hospital rounds on several patients there.  Most of them were receiving daily treatments with an expensive and potentially toxic medication for leishmaniasis, a relatively common parasitic infection in Peru that causes disfiguring skin lesions.  We also met one unfortunate young man in his 20′s with newly diagnosed, advanced liver cancer related to an ongoing hepatitis B infection.  (They were trying to arrange for treatment for him.  Hepatitis B vaccine is now required for all children.)  All of the physicians there are sisters.  It was an incredibly peaceful and clean environment maintained by an industrious and conscientious staff.  There were no televisions, video games or other noisy distractions.  It was clear that the men on the 2 wards were grateful for the compassionate but no-nonsense treatment that they were receiving. 

We also saw a man in his 40’s with a  very large Echinococcal cyst in his right lung.  This condition is caused by larvae that hatch from ingested dog tapeworm eggs.  Its size and location pose considerable risk for spontaneous rupture and death if not fixed.  The necessary surgical treatment is complicated and, for a poor farmer with little money and no insurance, prohibitively expensive.  One potential option was for him to apply for and receive hardship healthcare coverage to have the procedure and follow-up care done in Cusco.  To be eligible he would have had to return home and stay there until he was properly vetted and then approved.  The process is neither simple nor seamless and could have taken weeks and possibly more than a month to consummate.  The tropical medicine group has a fund it can use to help underwrite medical expenses in special cases.  It is generated in part by our tuition and also from donations.  Concerned because of the urgency of his situation (he was getting worse even while we were there), the Gorgas staff initiated the process to bring him to UPCH in Lima.    I don’t know the outcome yet.   You can read about the case at: http://gorgas.dom.uab.edu/2010cases/100315.html.

A day in the life

As each week goes by, I feel like the victim of a frontal assault. Yet another different presenter offers wave after inevitable wave of new information. Don’t get me wrong, I am not complaining. This is what I signed up for. They have delivered on all of their promises and then some. My knowledge (I hope) keeps growing.

Taken as a whole, this is an outstanding course. Their evolution seems similar in many ways to what we have tried to do at Wilderness Medical Associates. I have picked up some good ideas from how they do things. Like us, they hand out a printed version of each PPT lecture. Because they use 6 images per page, some of the graphs and charts are nearly impossible to read. 3 per page would make everything more readable but would double the amount of paper. I would have to hire a caravan to get everything home. Fortunately, we have online access to all of the lectures until we leave in April. This is great because you can read the charts and see the color version of all of the picts shown in class. We also have a case study book, much like our SOAP notes book, in which we can record information about all of our patients.  Combined with the photos of x-rays and other clinical findings recorded and shared by one of our group, we will leave here with some wonderful clinical information.  The lab sessions relate directly to things that we have already covered in class – e.g., microscopy of parasites. On some days, instead of a lab, we use case presentations to generate discussions about some important and interesting topics. These discussions can revolve around different clinical manifestations of a disease, differential diagnoses of a a symptom complex or dilemmas in treatment. They are frank and with regard to treatment, don’t always agree with the CDC, WHO or Partners in Health.

The late morning and early afternoon sessions (clinic and lab/discussion) are conducted with small groups. These are the most fun for me. There are 5 – 6 people in the clinical group; 8 in the lab/discussion. Each of the 2 groups is composed of different combinations of people. You stay with each for the full nine weeks. It is obvious that they tried to mix the groups up to reflect the heterogeneity of the class. Personally, I relate most closely to my clinical team because it is smaller and we talk about our patients in a more intimate and interactive way. This group includes two Canadians. One is a family practice physician who has finished an infectious disease fellowship and is now doing one in critical care medicine. The other is a nurse from BC presently doing ED locum work in RI. There is an infectious disease fellow from the Dominican Republic, a family practice physician from VT, and an internal medicine resident from Boston who will ultimately do dermatology. Each is motivated and bright.  I will say more about them later if they give me permission. The other group is equally diverse.  It is a pleasure to be with either group. 

In general, we are given an introduction to a topic and then revisit it in different formats several more times. Malaria is a good example. It has been covered in one form or another each week. After some introductory information we have talked about the 5 different types, their natural history, prevention, diagnostics (high and low tech) and treatment of both routine and life threatening presentations. In the lab we have looked at smears, made them (thick and thin), seen the rapid tests, and then looked at smears again. On Friday, we spent nearly 6 hours looking at pictures and then perused known and unknown slides. We got another chance on Sat including a guided tour on a multiuser scope, driven by an expert from Montreal. Then at the end of the course, we will traveling to Iquitos on the Amazon to visit a malaria research station (think Fitzcaraldo).  Malaria is much more complex than I realized but, with some apprehension, I believe I could approach a potential case with some confidence. That represents a huge amount of progress.

I am working on a couple other dispatches but given my writing skills, they are taking a long time. I hope this will suffice.

DJ