Course

Our home for the 5 days was turned over to the Japanese by the US government a number of years ago. Despite the downsize, the US military still maintains a substantial presence here including the remainder of the base across the road from where we are teaching. We heard reveille, the US national anthem and artillery practice from there, daily.

The Japanese government turned this parcel into a conference center. It is not typical of most US conference centers. The class rooms are large and spacious with comfortable seating and good technical support. The living accommodations are much more basic. Although I had a bed in a small room, many rooms are large open spaces where participants slept on futons piled on tatami floors (woven, mat-like). Dharmasuri and I had similar accommodations when we were here last January. We shared the center while with a number of groups with a broad spectrum of interests from adults to kids as young as 5 – 6 years old. Our meals are buffet-style, with some greens and sprouts, dishes with fish or pork and noodles. There is always enough vegetarian fair, and of course white rice with every meal. There was as a relative paucity of fruit and no dessert to speak of.

Each morning at 0600 we are greeted by announcements. At 0700 we have a community assembly complete with a flag raising, a speech or 2, and stretching. Everyone knows the drill. From childhood most people go through the same exact stretching routine called “radio stretching” accompanied by the same tune. When there are children here they raise the flag and stand out in front leading the stretches to music and narration. The other morning 4 kids raised the flag. It was hilarious. The point is to raise the Japanese and center flag in unison to the national anthem, reaching the top just at the end. The kids struggled with the process, getting the halyard twisted in the pulleys and either getting the flag to the top too soon or in a mad rush after the anthem was completed. They were kids being kids. Not once did any of the adults seem angry or frustrated. In fact everyone got a good laugh with their efforts. In addition, the kids had daily clean-up chores around the facility including their rooms.

I continue to be impressed with how well Isamu and Tak (our 2 Japanese instructors) translate for me. This is not as easy as our usual courses because of the amount of technical language used in the Wilderness Advanced Life Support course (WALS). Neither of them have a strong clinical background. It is an ongoing challenge but one we are all meeting. The feedback from our students bear this out.

Tak was worried on the last day because several students complained to him about the course the night before. He wasn’t sure if he should tell me. Because of the varied backgrounds of the students and the instructors I work with on this course, each course has a different feel and emphasis. I think the people he spoke with were expecting more practical skills and less medicine. Although we cover a lot of skills (and this one had more than most), the focus really is on how to use medicine in a remote environment. I sometimes joke that this course is a bait and switch. We entice people in with the word “advanced” but then downplay the value of technology. The advanced part has more to do with knowledge and its application than it does with tools and medication. And when it comes to patient care, basic skills may be even more important. True to form, the most experienced are the most restlessness about having to sit through the basics. They are also the ones who come up short when it is time to perform. My job is to offer opportunities. There are lessons to learn; some students are more open to learn them than others. The beauty here is that it is up to each individual. You can’t possibly meet all of their needs but we do try.

In the end the course turned out okay. The critics were quite happy and the vast majority of the students were thrilled. I have learned to temper my emotions and expectations about each one of these.

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.

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.

Healthcare Part 2

Peru seems to be making a really concerted effort to grapple with the large health issues that face their citizenry. One way is to provide healthcare coordinated through community clinics. The other morning we took a tour of one of them. The center serves a community of 33,000 people. It is one of about 10 other satellites in one of the regions in Lima. It in turn supports 10 smaller satellites. Their mission is to provide routine medical services (including obstetrics with 150 deliveries/month), emergency care, and education for the local citizenry. It is in a poor working class community surrounded by squatter’s homes on a hill, smaller in magnitude but similar, I would guess, to the favelas in Rio. As Peru’s prosperity has burgeoned modestly over the past decade, this community has as well.

The centers have targeted pregnant mothers, infant and child health, Tbc, HIV/AIDS, population control and sexually transmitted diseases. The clinic is the hub for providing public health information and support as well as prevention and treatment for common and important problems. Their approach to Tbc provides a good insight into how they work. If you read Mountains Beyond Mountains you know that Peru has had problems with Tbc, and especially the multi-drug resistant variety (MDRTB – multiple-drug resistance Tbc). Patients with high risk symptoms (e.g., persistent productive cough, fever, weight loss) are encouraged to go for an evaluation. Family members can ask for advice and clinic staff will make home visits. Once identified, Tbc patients are placed in a Direct Observation Treatment, short course (DOTS) program (http://www.who.int/tb/dots/whatisdots/en/index.html). This includes being placed on a database where information about attendance at the clinic is recorded. When they miss there is prompt follow-up. Scrupulous adherence to a medication regimen is essential for cure as well so to minimize the possibility MDRTB. HIV/AIDS and Tbc are bad for each other so all Tbc patients are tested for HIV; all HIV patients are screened and monitored for Tbc. Anyone testing positive for HIV is treated, the medications supplied by the clinic for free. They also check all family members including skin testing (PPD).  When appropriate, preventive and/or treatment medications are provided, too.  Children are particularly vulnerable to developing Tbc with 2 years of contact from someone that they are living with. Tbc in kids can be difficult to diagnose and they suffer with some pretty awful varieties. Kids are very important to Peruvians so they have tried to be proactive. This includes BCG vaccination at birth.  The real question is whether or not this has been effective. Peru has identified as one of the 20+ countries with real problems with Tbc and the emergence of MDRTB. It was one of 2 that has made substantive improvements within the past decade. Still, Tbc is a disease of poverty and poor nutrition. One need not travel far from the comforts of Miraflores to see there are still huge obstacles.

The clinic also screens all pregnant women, sex workers, and people with sexually transmitted infections (STI) for HIV. Birth control advice is offered and a wide range of options (excluding abortions) are available, including tubal ligations and vasectomies, all for free. The clinic also offers sex workers regular checkups, safe sex counselling, and treatment for symptoms of STIs by protocol, all free of charge.  This focus on STIs is important for Peru because unlike the US, HIV is spread here predominately by sex and not IV drug use. In the US there are people who would take great exception to public funds being used in these ways.  Despite the fact that Peru is a Catholic nation and is at least as conservative as the US with regard to sexual matters, many of these efforts thrive under the radar because they are directed toward the poor.

One additional observation. Historically, the spread of Tbc to healthcare workers was low until the late 1940’s. It has been going up since. The changes in hospitals over the past 60 years have no doubt contributed. Rather than open windows, modern hospitals now rely on closed ventilation systems. These systems are no match for the breezes that used to sweep in and through a hospital wing’s worth of windows. Ultraviolet (UV) light (aka sunlight), the bane of existence for Tbc, is in short supply in buildings with roofs, long hallways and few windows. Given that Tbc is spread by droplets, it should come as no surprise that resistant strains spread when people with TBC come into close contact, especially before their treatment has started taking effect. It would seem that bringing infected people together at clinics for DOTS would be a disaster waiting to happen. The solution? At least in the clinic we visited, Tbc patients wait outside on benches in a patio, bathed (at least metaphorically) by sunlight and a breeze rather than in a closed, cramped waiting room. This is not a great solution for Siberia but it makes sense here and in tropical and subtropical climates generally.

The clinic and its surroundings were clean and the patients and staff seemed positive and enthusiastic. Although this was prearranged, I don’t believe that we were just given a photo op. Quite frankly, their efforts embarrass me as an American when I think about what we do and do not do with our resources.  We have a president with a majority in both houses and still they squabble with special interests while the really important discussions about the fundamental issues of healthcare queue up behind what seems like a lot of nonsense.  Peruvians, with limited funds, have decided do something by addressing the problems that they perceive will have the biggest long term impact on the future of the country.  They have had to make difficult decisions, limited by resources.  In some cases, these decisions have resulted in interesting innovations.  Microscopic-observation direct susceptibilities (MODS), invented in  Peru, provides a faster and cheaper way to grow Tbc in culture and determine drug susceptibilities. 

No one knows if these are the right problems or solutions but Peruvians are trying and they seem to be making headway.  Many of the instructional staff here at Gorgas are seriously involved in the dialogue.  I am proud to be associated with them.

Healthcare

Because I am working and studying medicine here, I decided to try and describe the Peruvian medical system. I use the word try because language and opinion are big obstacles. Even when you know the language and work within a system, it can still be difficult to compose a concise, understandable and accurate description. I know because I found it to be similarly difficult when I worked in Canada and the UK.  Forget the US.  Please don’t view this as a whitepaper report. These are my observations from watching, listening and asking some questions. It focuses on my encounters which are mostly in hospital. I have little doubt that there are nuances that I have missed along the way.

For hospital care, there are essentially 3 tracks.   As in the US, you are responsible for your bill, less that part covered by any insurance you might have. The private option is just that. I don’t know if people who utilize this system have insurance or if this is all out of pocket. The appearance of the hospitals and clinics suggest that at least the quality of the facilities if not the medical care is superior to that found elsewhere. I have never visited one of these. There is also what some people refer to as social security. This is a system available to everyone (?) who has a job.  These people have public insurance that is subsidized by employers and employees. Who pays what toward the insurance depends in part on the work that one does. The actual  opperation has evolved over the past 15 – 20 years so it is a work in progress.  Not unlike the US, your coverage has limitations. The third group includes those who are poor and have no insurance.  These patients find themselves in large wards holding 6 or more people.  And many of these people put off seeking care until they are really quite ill.  Ironically, often they turn out to have conditions that are covered by government programs (see below).  I have no idea about the insurance status of most of the patients that we see at UPCH and the other facilities but I do know that at least part of our tuition here helps to subsidize care for some of our patients. 

It is not clear to me that there are COBRA-type regulations in Peru, where everyone is entitled to a screening evaluation and medical stabilization regardless of one’s ability to pay. In the US the definition of this level of evaluation and treatment is very broad and can be quite intense and comprehensive in part because of medical legal concerns. Although US hospitals ask about insurance coverage in the emergency department (ED) no one can be denied an evaluation, care or admission for stabilization of a serious medical problem. Most of the time, decisions about testing and treatment are not consciously weighed based on a patient’s ability to pay. Our system seems to do what is necessary and then hand over the bill. Things are different in Peru. It is clear that testing and medical treatment are predicated on the cost and therefore a person’s ability to pay for it. Tests and treatment can and are withheld for financial reasons. I have seen more than one person await necessary and important surgery, because as I understood it, a surgeon willing to do what amounted to charity work could not be found. The financial consequences are more in the forefront here while in the US we act first, sometimes bankrupting our patients afterwards.

There are some caveats. A hospital bed is much less expensive in the public hospitals. There are also physicians who see patients without apparent regard for a person’s ability to pay. Some work in more than one venue, earning their income one place and doing work pro bono in another.  Those who I have met are compassionate and dedicated to do their best with limited resources. It is remarkable how creative they can be when diagnostics and medications are limited because of money concerns.

Before you allow your indignation to get the better of you, there are some other wrinkles here that, quite frankly, embarrass me about our own system, such as it is. Certain people and diseases are covered by the government. These include HIV/AIDS, tuberculosis (Tbc), sexually transmitted infections (STI), pregnant women and children up to at least 2 years of age. Peru is not a wealthy country but some forward thinking people within healthcare have made some hardball decisions about where to focus limited resources for the biggest bang for the buck. There have been conscious, medically sound decisions about which to include. For example, all children receive vaccinations for free. Although kids receive most of those given in the US, decisions have been made based on epidemiologic factors such as infant mortality data. They do not administer varicella (chickenpox) but do give BCG, against tuberculosis. It is possible to point to monitoring data and demonstrate the validity of these decisions based on concrete results. The other really interesting feature is the community clinic system that is an integral and important part of sound, affordable health care policy.  I will say more about this later.

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

Getting to know Lima

Living and working (or going to school) in another country is a wonderful experience. It allows for a more relaxed pace than tourism and therefore more of an opportunity to learn about the people and the way of life in another place. It should come as no surprise that this will not be about the subtleties of cerviche or some of the other Peruvian delights. I am an observer of behavior; I don’t let my local illiteracy get in the way.

There is no better way to get a sense of your surroundings and see people in action than to watch and be involved in traffic. Each place has its own rules and customs. Those of you who have traveled outside of N America and W Europe have some idea what I am talking about. Lima is no different. Although I don’t drive here, I walk a lot and each day we ride a bus more than 45 minutes to and from UPCH. When I can, I ride shotgun.  This is a wonderful vantage point from which to observe Lima’s own brand of chaos and convention.

As in the US, there are traffic control lights to help manage flow. On the whole, people obey intersection lights much like we do, pushing the late green to early red. Curiously, there are also traffic lights in some of the traffic circles (rotaries /roundabouts). A stream of traffic can be stopped right in the middle of the circle by a red light to allow a fresh stream of vehicles to enter it. This system works surprising well during rush hour. Eventually everyone gets in. Getting out is a different story.

Where there aren’t traffic lights or where bottlenecks occur, police officers help control the flow. Without exception each one that I have seen is a young and attractive woman. Each wears her hair pulled back tightly in a bun, covered with a hard hat. All of them wear a crisp tan uniform that includes very tight-fitting jodhpur-like slacks. None is overweight. Whether they are stationed in curious little elevated booths located off to the side of the road or standing out in traffic, with whistle in mouth they have a remarkable degree of control. The other night I walked up to a usually busy intersection and found it completely gridlocked. The intersection was uncontrolled – no traffic lights or stop sign . Blaring horns and flashing headlights were no more effective here than anywhere else. But then, one of these traffic control officers materialized out of the darkness on a small motorcycle. She drove it onto the sidewalk, pulled it up on its stand, and went to work. Wading into and contributing to the cacophony with her screeching whistle, this young woman took control. With her arms waving and pumping she muscled and finessed the traffic back into its usual disorder. In less than 15 minutes she left as stealthily as she had arrived. It was a scene out of the Lone Ranger. Where does this control come from? Perhaps these women appeal to a secret desire to be controlled by mother or some sort of mistress in the uniform of a disciplinarian. All they need is a riding crop.

Traffic flow and navigation are mysteries to me. What they do and how they respond probably says something about Limeños (not Limones, those are lemons). In heavy traffic, the goal for all of us is to get ahead to get home.  The goal may be the same in Lima but drivers here have their own unique twists. In Lima, the concept of yielding does not seem to exit. There are very few such signs.  If they are observed, they are not obeyed. Size and position rule. Opportunity is also important. Drivers straddle lines, signaling in one direction while veering subtely toward the other. I don’t believe that these are acts of willful deception.  Rather, they seem to indicate that any action is possible. As a result, very close calls occur moment to moment but actual collisions don’t seem to. I have not seen one despite MANY opportunities. The most amazing move, however, is the right hand turn from the far left lane, turn signal optional, direction unimportant. Although these turns feel and look impulsively dangerous because of how abruptly they are executed, I have come to realize that this and other similar tactics are neither.  As traffic creeps slowly but surely forward en masse, no one yells, gives a finger or otherwise expresses anything other than determination and resignation. 

The concept of pedestrian right of way is simple to understand here, there is none. Size and speed matter. Horn toots and flashing lights somehow modify intent and meaning but the subtleties of these messages escape me. Most turning vehicles (and all taxis) accelerate as they approach uncontrolled intersections. These attitudes help to define the concept. At an intersection, drivers look past you to oncoming traffic. If there is space, they continue accelerating into and through the turn as they move ahead. Although crosswalks are not demarcated by the familiar thin, double, parallel lines that run perpendicular to the flow of traffic, they have what I thought were the other style. At many intersections, whether or not controlled, they have wide and fat, white parallel lines painted parallel to the flow of traffic, marching from curb to curb like a column of hypens in tight order.  Many are preceded by a broad, white line.   At home, these mean traffic must stop for any pedestrian in the area bounded by them. Not here. As best I can tell, their purpose is to highlight a person crossing the street by offering a contrasting background. It is like shining a different color light on a target from behind for better visibility. Again, I have never seen anyone hit. I don’t’ push my luck.

DJ

First impression

Lima is an enormous city, 8 million I am told. I am living in a section of the city called Mira Flores. Its major roads begin at the Miraflores Oval and then radiate out like the spokes of a wheel. They end at the rim, a coastal cliff at least 100 m (over 300 ft) above the beach. The coast is oriented NW to SE. There is a coastal road below and a thoroughfare along the edge made up of a continuous series of quiet streets that contain Malacon in their names. It is pretty upscale. There is a well-maintained park with running and bicycle paths paralleling the Malacon. The park is populated by painted cows – seriously. It is part of a campaign to raise money for charity. We had something similar in Portland a few years back. Instead of cows, they were lighthouses. The temperatures are moderate (mid to upper 20s down to low 20’s/lower 70s to lower 80s) and with the breeze, very comfortable day and night. Despite the proximity to the Pacific, I am told not to expect any rain in Lima. In fact there are areas S of here that quite literally never receive any rain.

Mira Flores and its neighbor, San Isidro, are pretty prosperous. The course directors did not make this choice serendipitously. There is a lot to do and the food is good. It also seems generally clean and safe, especially compared to some parts of the city that we travel through on our trips to other hospitals outside of our home base at the Universidad Peruana Cayetano Heredia (UPCH).

We are carted off to the UPCH at 0715 and then deposited back in Miraflores at about 1730. The campus itself looks like a low security “green zone.” The area is fenced in and entry is controlled at a security gate. Our day begins officially and promptly at 0800. This makes me feel right at home. The only difference is that I am sitting looking toward the front at one person rather than back out on a pod (or is it gaggle?) of students.

The morning consists of 2 one hour talks followed by a 2 hour, small group clinical session. At the later, we review the relevant clinical information, perform focused exams and then discuss possible causes and treatments of 3 – 4 interesting patients. After lunch, we participate in daily labs (malaria introduction and helminths or worms this week) and then attend a final 1 ½ hr lecture. There are field trips on some Saturdays as well. Tomorrow, for example, we head to the Andes to look at working conditions in some of the high altitudes mines.  Our final destination will be at about 4700 m (over 15000 feet).  On the whole, this seems like a well thought out course that is packed with great information.  It is and will be a challenge for me. 

We have 32 students from around the world but most are from Canada, Australia, and the US. Infectious Disease physicians are heavily represented. They all seem bright, knowledgeable and eager. I will talk about the trip if it is interesting and give a little better idea what a typical day is like later.

The word for the week is tuberculosis.

DJ