Opportunity

Nansen and I are doing our HIV/AIDS surveys at the universities in town. Yesterday we were at Universidad Nacional Andina del Abad de Cusco (UNSAAC). Its a public university, the largest in town, and very well respected. There is an entrance exam that every student needs to take and get a minimum score on for entrance. And apparently the minimum score is very hard to achieve. There is actually a special pre-University school students can attend after colegio (high school) just to prepare for the exam. Some students take up to years to prepare. Some students never get the score they need and end up at other universities. In addition to having a wide range of subjects and being well respected, UNSAAC is also free to anyone who gets in. This is obviously a huge deal for anyone from a middle to low income family.

Yesterday as I was waiting for people to finish their surveys, I looked around me. We were in the quad between the tourism, economy, and one of the engineering buildings. The buildings were all white, very modern, with scaffoldings enclosing external staircases. I could see in the windows of the tourism building and see classrooms with polished white floors, computers, and projection systems. Behind the building I could see the houses that are built into the hill side of the Cusco valley. These houses higher up and harder to get to and generally where poorer people live. They are constructed out of dirt adobe blocks. People cannot afford paint or tiles for the outside of most homes here. Clothes lines stretch across the roofs as almost no one here can afford a washed or drier. Things such as framing around windows, doors, and other niceties are also nonexistent. I thought about the houses in the campos I've seen. Dirt floors, sometimes only one room, wood-fired ovens for cooking. Barely electricity, much less televisions or phones.

Suddenly I understood in a different way what a really incredible opportunity UNSAAC must be for some families. Not in the way we talk about it at home- do what you want, make a little more money- but truly life changing. And not just for the student, but for their family as well. These buildings are like nothing else in town. Its easy to see how even just getting to study in one is an amazing advantage. Not to mention job opportunities and health insurance and the knowledge of how to look out for oneself in this complicated and quickly changing world. I wonder how many students in the US properly appreciate their colleges.

Speaking of appreciating our colleges: Oberlin just got named #3 healthiest college dining hall in the country! http://www.huffingtonpost.com/her-campus/healthy-food-dining-halls_b_1117652.html

Terremotos

Terremoto is the spanish word for earthquake. There's the Nazca tectonic plate that is along the coastline of Peru and it likes to move around and cause earthquakes, much the same as the North American plate does in California. Most of the biggest quakes happen closer to the coast, especially around Lima. Once in a while a doozy will hit in the mountains though. In 1984 there was a huge one that shook Cusco and the entire Sacred Valley. Buildings fell down, roads collapses, bridges crashed, and a lot of people died.

Some buildings in Cusco are constructed in a more traditional way- with adobe blocks made from dirt and dried in the sun. Others are made in a more European style with more solid concrete. In the spirit of Gandhi and Mandela and all those who have rejected that European = better; the traditional buildings actually hold up better during earthquakes. The adobe blocks have wiggle room and can absorb the shifting earthquake better. Other buildings collapse because they have no wiggle room. Obviously the poorest people get the worst of the deal because they just live in cardboard shacks which stand no chance at all.

The buildings of Hospital Lorena (multiple buildings because they couldn't build up at the time of construction 70+ years ago) are made in the newer, worse way. Therefore today we had an "earthquake drill." Everyone got called out of their work and had to stand between the buildings. They drove an ambulance up a sidewalk to use its loudspeaker system. Several people talked about the need for earthquake readiness for quite a while. There were several patients out there too- in wheelchairs and gurneys and hospital gowns.

I couldn't help but thinking as I was standing there that an earthquake drill is not inherently weird. But it would never fly in the US to call outside over half the staff away from their work. Especially in the morning when rounds are happening. Just another way different countries are different.

As we were waiting I was talking to the peds intern. He was quite surprised to learn we don't do earthquake drills regularly. We talked about where earthquakes are common in the US, and hurricanes and tornados and what drills we usually do in school. Fire drills are apparently unknown here, where at home they are the most common.

Pediatrics in Peru

So I spent the last two weeks working on the peds floor. Below are some of the things I've observed/thought about while there. Mostly medical stuff.

They use the light from the windows to read films.

There are usually three attendings on rounds.

Nurses keep track of weight, temperature, heart rate and respiratory rate on flow sheet. They also have daily logs for each patient’s fluid plan, if they need ins and outs recorded, and what tests are pending.

Lots of oxygen is used but pulse ox (oxygen level in the blood) readings are rarely tacken or recorded. There is no continuous pulse ox monitoring even in the ICU bed. I've never even heard of an ICU patient in the US without continuous pulse ox monitoring. The ICU beds do have continuous heart rate and respiratory monitoring.

The most common treatment for UTIs is ceftriaxone. When they want better gram negative coverage they add amikacin. I only saw VCUGs scheduled for patiets with prolonged urosepsis. I did not see VCUGs scheduled for repeated UTIs, UTIs for patients under 2, or for boys with UTIs as the recommendations suggest in the US. (VCUG is a test to look for structural problems as the cause of urinary tract infections in kids.)

For pneumonia there is not a standard first line treatment. I saw amoxicillin, azihromycin, and amikacin used most often. Gentamicin and ceftriaxon were used rarely. Kids were hospitalized for 7-10 days for pneumonia treatment.

Paracetamol was used preferentially for fever. When fevers spiked repeat blood cultures were not drawn even if it was more than 48 hours since the last cultures. This was patients didn't want to pay for this or doctors assumed patients wouldn't want to pay for this.

There are no pediatric specialists for organ systems such as pulmonology, gastroenterology, or cardiology. The adult specialists consult for pediatric cases too. Consults do not write full notes with their exam findings, only their diagnosis and recommended treatment plan. This makes understanding their thinking very difficult and caused some confusion.

Interns write their exam and subjective part in the morning. Attending dictate their treatment plans during rounds. There is no assessment. The list of diagnosis includes both confirmed and possible diagnosis (usually with d/c proceeding it but always.)

Attendings make all changes to oxygen levels and also swith out oxygen tanks when needed. These are giant 4.5 feet tanks. There is no wall access. Other people seem afraid to touch the oxygen.

There are signs everywhere asking people not to charge their cell phones. The hospital does not want to pay for the electricity usage.

There is a poster from a child's point of view sayig they wish they were a t.v. so their parents would love them and pay attention to them.

The resident has an on call room and the end of the unit next to the TB isolation room. The TB isolation room has 10 feet of open air space that communicates with the rest of the unit. Not ideal for preventing transmission of an air-borne disease.

In the campos (country) closed houses with indoor ovens are a common exacerbating factor for asthma. Asthma is more common in cities though because of car pollution.

People are very upset that now there is one obese child in every classroom (about one in twenty). They say in the past there were never obese children. People blame different things but the list includes video games, t.v., pop, bad parental example, and not walking as much.

Salumedrol is the first line beta agonists used for asthma. Albuterol (used all over the place in the US) does not exist here.

Lumbar punctures are rcommended for any child with suspected meningtis infection, Glasgow coma score less than 15, or other focal neurological findings. Betamethasone (steroids) is always used with the initiation of antibiotics for bacterial meningitis. It is also always used for suspected or confirmed TB meningitis. They seem to be on the side of debate that it is always helpful. No one argued the other side that it might not be that useful.

One parent is allowed to stay with their child at all times. Other family can visit during visiting hours, which is only between 1-3 pm every afternoon. On weekends this is extended from 1-4 pm. Patient's whose families come from the country simply sit outside all morning waiting. Parents bring their own food, diapers, clothes, toys, for their kids.

Soccer at 11,000 feet

Here is a little life skill that I never picked up and do I ever regret it now. It wouldn’t even be so bad if I could at least keep up with everyone else. It might be the altitude or the fact that I’m grossly out of shape and haven’t been able to run much because of my bum knee, but I suck. At least I have people to play with. I started playing a weekly game with Spanish teachers from a few schools. The first week I played 3 v 3 on a court about the size of an NBA court. I was out of breath in about 15 minutes and about 30 minutes, I was pretty much squatting down every couple of minutes. I had about 5 opportunities to score and blew them all.

I just came back from my second today. I played ok for the first 20 minutes on a smaller court. The turning point, though, was when jostling for a ball, I accidentally launched it about 30 feet out of bounds. This is the best part, turns out it landed inside a police station. Furthermore, it landed in a  kennel! I had the unfortunate duty to ask the policeman to help me find the soccer ball. Kennels are scary. Good thing the doggies were behind bars, but remind me never to piss off a police dog. Apparently the police thought it was so funny that a gringo lost the soccer ball. Apparently the dogs like the flavor of foreigners. Thanks. Asshole. I blew a couple of good opportunities to score and pretty much was relegated to goalie by the end. Suck suck suck. Oh well, I’ll keep at it, and hopefully I’ll hold my own. At least I am having fun sucking. Maybe Kate also enjoys her evening without my harassment.   

Clinica disastro

So after five weeks of trying to find our place in the clinic, Nansen and I have given up. I think there is some degree of cultural differences at play, and I think the clinic is just not ready to handle having volunteers right now.

One of the nurses and the administrator at the clinic had come up with this idea to do home visits in the community. Now this seems like a great idea. I've read and seen lots of things in the states talking about the growing need for home visits. Not only are the important for patients who are older, immobile, or terminal; but studies have shown that it can actually save money. Patients don't have to pay for transportation to hospitals when things get too bad, but can find ways to manage their health care at home. The neighborhood the clinic serves is low income, so this seems like a perfect project. People who can't get to the hospital on their own and may not be able to pay for help getting there.

We made our own forms for this project, as the clinic didn't really have any. Our forms were designed to assess the health status of every member of the family- functional, nutrition, hygiene, mental status, and physical health. Then there were additional pages for complete histories and physicals for each member as needed. We also have forms to formally assess for caregiver burnout, dementia, depression, etc.

Unfortunately the clinic does not seem to have the staff or the scheduling to support this project. Despite repeated attempts to go out with nurses or on our own, things have fallen through time and time again. I believe its time to move on to another project.

We have contacts at both the public hospitals in Cusco- Antonia Lorena and Regional- and hopefully will be able to start volunteering there as early as next week. Either should be a very interesting experience as to how hospitals run in another country, what diseases are seen, and how they are treated. I'm sad that things have been going so poorly at the clinic, but there are still lots of exciting possibility on the horizon.

Llama vs Nansen

I’ve always heard that llamas were mean animals. But how can that be? They are so cute with their shaggy fur and dumb looking eyes. One Friday morning, instead of sitting in class, my Spanish teacher Ricardo, took Kate, Cara (another student), and I on a field trip to the university. The first stop was the university zoo. Now this is no ordinary zoo. In fact, this might have been the most animated zoo I’ve ever been to. It shelters wild animals while they recover from various ailments, then return them to the wild. It’s the only zoo where I’ve been handed a toucan, turtles come in wheelbarrows, and the monkeys show you their…manhood.  

 

Anyways, there were llamas roaming the premises as well. One in particular was having an especially active morning. It picked on Ricardo first, attempting to bite him. Cusquenos, apparently, have experience with fending off llamas. He even put the llama in a headlock. After a bit of a struggle the llama went away. It came back a minute later, though, this time to try to eat Cara’s hair. Again Ricardo fended him away. I was next on the target list. The llama stopped a few feet in front of me and stared at me with those silly eyes. Like a dumb gringo, I put on a fighting stance with a dumb smile. The llama was not amused. It had had it with dumb gringos. It struck. It went on its hind foot, which made it seem about 7 ft tall, and proceeded to chase me down. When I decided I couldn’t outrun the llama, I turned to fend it off. Luckily for me, the llama’s charge was more fierce than its attack. All it tried to do was to extend its silly neck and try to bite me with its flat molars. It was easy for me to fend it off with my one semester of college Jeet Kun Do (intercepting fists!). I walked away but the llama followed me. After a few more rounds of this exchange, Ricardo came to the rescue. He grabbed its lease and tied it to a garbage can. Llama maiming averted!       

In summary: Ricardo tames llama, and llama tames Nansen.

Oh yea, and when I got home, Kate thought it would be funny to surprise me with a stuffed llama. I was safe though, it was tied to a Pringles can. Hooray!