Day 10 – Lima Layover – what a bonus!

We took our time getting up and ready this morning.  We had time for a great breakfast at the hotel which had an omelet station, papaya juice, hot coco, etc.  Our cab driver, Mr. Reliable was there waiting for us and got us to the airport within 7 minutes.

Beautiful Panorama from Cusco hotel room balcony

As soon as we got to the ticket counter we found out our plane was delayed and there was no definite departure time.  But if we really hurried, we could make it to the 10.00 AM flight.  We got through check in, security, hand check of bags and to the plane in 20 minutes!  We even had adjacent seats.  We were not sure what we would do with all the time we had in Lima (almost 10 hours) before our flight to the US.  Still we figured it would be better to get to Lima early than not get there at all!

Snow covered peaks seen from Cusco Lima flight

The flight was great, we had the same terrific views and we gained new appreciation for the mountaineers who scale these peaks, some without oxygen.  I promised myself (with crossed fingers) that I would come back some day prepared to do the 4 day Inca trail.

At the airport we were discussing what we could do in Lima when one of our colleagues from the medical mission (David) came in on a different flight.  He had not seen Lima at all and that made the decision easier.  Instead of sitting at the airport (my idea was to finish our blogs that day), we decided to go into town.

Kennedy Park with art exhibits

Lima airport allows you to store your luggage – either by individual bag or in a locker.  The price is by the our or by the day (if you store it for >4 hours).  We got a cab to Kennedy park in Miraflores.

Lima Cop on a Segway

There was an exhibition of paintings by local artists and we picked up some water colors on Quechua themes.  We then started walking towards Larco Mar which is a oceanside open mall.  On the way we came across a Bembos and had our favorite Tacu tacu.

I wanted to pick up a bottle of Pisco to take back to the US.  The best place to get this is at a local supermarket called Metro.  They had an Offerta (Deal) on a combo of Pisco+Ginger Ale+ Syrup for 32 Soles.  We tried to get just the Pisco for that price but they would sell that for only 51 Soles!  Go Figure.

Outside Bembos

Arguing in Spanish was not likely to get us anywhere.  So we got the set and drank the ginger ale walking along the street and sitting at Larco mar!  The syrup bottle we did not know what to do but the situation took care of itself later.

Reflecting pool at Larcomar

The view from Larco mar was terrific.  We spent some time absorbing the beautiful views of the Pacific.  There were many paragliders flying around off the cliffs and made of fun watching.  They would fly close to the high rise buildings and do flips and stunts that gave the watchers butterflies in their stomachs.

Larcomar from above

We walked along the ocean along a street lined with parks.  We ended up at a lighthouse just as the sun was setting into the Pacific.  The afternoon was a perfect ending to a most wonderful trip to Peru.

Lima layover become a bonus!

Looks like a Khajuraho sculpture

Panorama at Larcomar

Yes you are seeing triple!

Another triple panorama

Lighthouse at sunset

Para gliders at the Cliffs of Miraflores

Pretty proud of this shot!

As soon as the sun set, we started looking for a cab back to the airport.  This is when we found out that cab drivers need a special permit to drop people off at the airport.  Cab after cab refused to take us there and we started to get a bit anxious even though it was still 4 hours to our flight.  Finally one cab driver agreed to take us.  We piled in heaving a sigh of relief.  After a few minutes, the driver told us (via Sabrina who was translating) that he too did not have a permit.  He was scared the police would catch him and fine him a huge amount.

Goodbye Sun, Goodbye Lima, Goodbye Peru!

So he was going to drop us off a little ways from the airport!  Great we thought, having no real options.  When the airport came close he told us to grab our bags and hop off ASAP.  He barely came to a standstill and we were out on the sidewalk!  Luckily the airport was just across the highway.  We took a pedestrian overpass and walked into the airport.

We retrieved our bags and realized that we would have to check in the bottles of Pisco (and syrup since we still had it with us) since we cannot carry on any liquids.  So we started packing and redistributing the stuff and as luck would have it, the syrup bottle rolled off and hit the floor and solve our problem.

We checked in and having learned our lesson, ate at the Subway before going through security.  The international departure area, unlike the domestic one, does have several places to eat but as David said, “Subway is the US embassy in Lima”.  We had a very bumpy flight to Newark and a smooth connection home.  The Pisco bottle I am glad to say made it safely!  I was able to invite a friend to sample my first Pisco Sour on father’s day!

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Day 9 – Machu Picchu

Finally the day that we had been waiting for dawned – well not really.  We were up and ready way before sunrise.  The plan was to see the sunrise from Machu Picchu remember?  We had both my Blackberry and Sangita’s Motorola Razr set up with alarms to wake us up at 4.00 AM.  The water was steaming hot and we packed up, putting 6 water bottles and some snacks and bars into the backpack we would take up to the top.  We were wearing multiple layers of clothing and knew we would be peeling these off and carrying these later in the day.

We had hot breakfast at the hotel and left our bags in storage and walked down a short cut along the train tracks to the bus station.  It was cold and dark; would recommend walking in groups if possible this early.

Early morning line at the bus station Aquas Callientes

There was already a line forming with over a hundred people standing next to several buses waiting for 5.00 AM.  We bought return tickets using US dollars cash and got in line. Some of the medical students were well ahead of us but we did not want to jump the line as folks who are going up to Huyana Picchu think we might be denying them  a chance and can get pretty vocal.  Since we had no plans to do that hike, it was really a non issue.

The buses started off as soon as they were full and we were able to get on the 4th bus barely 10 minutes after the first bus.  On the way we encountered several folks hiking up to the top.  A lot of them were sitting, resting on the sides of the road.  I was glad I was not one of them.  I wanted to save my energy for hiking around at the top.  Remember that the air here is very thin and oxygen is scarce.  If you have not hiked at 8000 feet before, you can expect it to be a lot more demanding than what it is at sea level.  The average weekend warrior who knocks of a couple miles on a treadmill may not be in shape to enjoy this.

Sunrise over Machu Picchu

We were lucky to see the sun breaking out above the peaks as soon as we reached the top.  There were a lot of clouds and fog which made for a truly mystical sight.  We went through the turnstiles and picked up an English speaking guide along the way.  Guides tend to charge by the time and number of people in the group.  The regular charge for a group of about 4-5 people for a full tour (3-4 hours) is about 70 US dollars.  If you are lucky, you can get a guide who already has a scheduled group tour and has a couple of hours to spare prior to that.  We were able to get a 2.5 hour tour at a terrific discount.

Clouds and fog add to the mystique of Machu Picchu

There is a place to store bags at the top, so in case you don’t want to carry around all your layers of clothing, you can come back to store them here once it gets warm.  Remember this is easier said then done.

A lot of climbing to be done inside Machu Picchu

There is a lot of climbing to be done at Machu Picchu, so you may want to plan to drop these off before you start climbing up to towards the top of the ruins.  Ask you guide to advice you.  The tickets allow you to go in an out of the gates through out the day.  The bathrooms (Banjos) are also outside the gate.

Panoramic view looking north

I am not going to write much about Machu Picchu.  It is probably one of the most beautiful spots on Earth.  The Amazon forest theoretically starts here.  The vegetation, the topography and the incredible Inca architecture that blends the ruins into the mountains is astounding.  The clouds and fog make the place look mystical.

Eating the last of the dried spinach pancakes we carried with us from US

Tebowing at a very spiritual place!

When you sit at the top near the guardhouse and look at the view, you feel it pulling at your heart strings, you just want to sit and watch.  When we finally left we had tears in our eyes, not knowing when we will ever see this view again. We finally walked off quickly never looking back just in case it drew us back with its magical magnetism.

We did not do the Huyana Picchu trail – it sounded too dangerous to us.  At this point we just wanted to return home safe and sound.  We did meet up with 3 of our students who made it to the top and how one of them literally crawled up and down the last part as it was too steep and narrow and she was too scared to stand up especially with her backpack.  Our guide on the other hand just smiled and said he can do it in 12 minutes!

The trail to the Inca Bridge

We did take a trail to see the Inca bridge.  This is relatively an easy trail – not too much climbing up or down but is quite narrow in places.  The bridge itself is a rickety piece of wood/stone over a gap in the trail and you are not allowed to reach it.  The trail makes for some great photo ops.  If you are scared of heights, avoid it.

It took us a very long time to get back to the gates.  There were hordes of people coming in and some of the narrow stairs require you to stand to the side to let them pass.  On the way out, we remembered to get our passports stamped with Machu Picchu!  You can get this done right inside the gates.

We took the bus down to Aquas Callientes, exhausted, hot but satisfied.  A great capstone for an amazing trip.  We dropped off our back pack at the hotel, fired off some e-mails and then explored the village.  We had lunch at a nice restaurant overlooking the village square.  Finding a restaurant was interesting, we were looking at the menu at one place when another restaurant manger came out and telling us he could give us the same stuff, cheaper.  A bit of auctioning occurred between the two while we stood there bemused.  Eventually we went to the “lowest bidder” who threw in free drinks (including Picso sour) and appetizers!

Restaurant overlooking the main square

The bonus was really a huge flat screen TV that was playing a Portugal – West Germany World Cup qualifier!  While waiting for the meal, we saw some of the medical students in the square below and they joined us for lunch.  After a great lunch we got to say goodbyes again to the medical students who had by now become great friends.

Sangita of course needed to do some last minute shopping before we left for Cusco.  Aquas Callientes has a nice mercado and we picked up quite a bit of stuff since we had space in our bags.  Sadly, soon it was time to leave.  We picked up our bags at the hotel and walked down to the train station.  Our Australian friends were in the adjoining seats again and we carried on the conversation from where we had left off.

Fashion show and a Shamam on the train

After the first 30 minutes, it got dark and we tried to nap.  But the train crew started up some very loud music, did a fashion show displaying Alpaca garments and we were unable to sleep.  Finally we reached Poroy the station that serves Cusco.  The cab driver who had left us at Ollantaytambo was here to pick us up (we had arrange for him to do this the day before) and we were glad we did not have to wait for transport.  Poroy did not seem to have a lot of cabs waiting at that time of the evening and we mentally thanked Edwin our hotel owner at Urubamba for suggesting this arrangement.

We stayed at the Eco Inn Hotel at Cusco which is an excellent facility.  Our luggage that we had sent ahead from Urubamba was waiting for us and delivered to our room without us even asking for it!  We showered and redistributed and repacked our bags for the flight the next day.  We were going to take a 10.40 flight to Lima and thus would be able to sleep in for the first time on this trip!

That night we dreamed of Machu Picchu, and I woke up several times at first with images of standing on a cliff edge.  But we were all too tired and soon fell into a beautiful, restful sleep.

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Day 8 – Lamay, Ollantaytambo and Aquas Callientes

This was a bit of a bitter sweet day.  It was the last day of clinic for us and we felt sad that this phase of our trip was over.  We had enjoyed the experience and hopefully made a small difference in the lives of some people.  We had made great friends and learned a lot about the Sacred Valley and its people.  The medical students had been impressive in their energy, planning, zeal, adaptability and collegiality.  Sangita was a bit concerned that there was no ophthalmologist following her after we left but also quite confident in the skills of the many students that had worked with her the previous 5 days.

At the same time we were looking forward to Machu Picchu and hoping it would live up to all our expectations.  The plan was to go to clinic and then around 3.00 PM have a cab pick us up, take us back to the hotel, pick up our bags and leave for Ollantaytambo where we would catch a train for Aquas Callientes.  A few points regarding logistics to help future visitors to this area:

  • The train has limited space for carry on bags.  This is particularly true of the Vistadome trains.  We did not see anyone being stopped but if you do have huge bags it might be a problem.  Also, if your hotel in Aquas Callientes is not close to the station, you will have a lot of hard work to do.  So you want to take only the minimum amount of stuff with you.  Most people leave their larger bags at their hotels and just take a back pack.
  • We were going to not come back to our hotel in Urubamba, instead going straight to Cusco.  Senor Edwin the hotel owner/manager suggested we send the larger bags via cab to our hotel in Cusco.  He guaranteed that they would arrive safely there and be waiting for us when we got there.  This was excellent advice and much appreciated.
  • There are several types of trains – with the Expedition and the Vistadome being popular options.  Vistadome’s claim to fame is the better view of the surrounding landscape for a slightly higher price.  Before you splurge on this, check the times for sunset/sunrise.  In June, it gets dark by 6.00 PM in the valley and you won’t be able to see much.  Also the Vistadome has less luggage space as noted above.
  • If you have a relatively inflexible schedule, you want to buy your train tickets online ahead of time.  The major barrier is the problem with the web site accepting credit cards.  If your card does not work, you can contact them via phone/email and email a scanned copy of your passport and credit card to get confirmed tickets.

We took a public bus to Lamay Clinic which is where the Peru program started.  It thus holds a very special place in the history of the Peru Health Outreach Project.

Garden at Lamay Clinic

The clinic is very nice and clean with a small garden in the courtyard.  We saw a lot of more complex medical problems here. We did still have quite a few patients speaking Quechua only even though this was not quite as rural.

The medical director of the clinic was able to help us with some translations but one of the most helpful people was a patient.  He was way back in line but volunteered his services to help other patients.  We would call him in to help and then he would go back to his place at the back of the line.  Even other patients in the room pitched in to help and HIPAA seemed to an issue from another planet.

I will not forget one of the patients we saw.  She spoke only a bit of Spanish but we did not realize this right away as she started responding to our questions in Spanish.  It seemed she had stomach pains and wanted pain medications.  We were unable to determine the cause of this by history or exam.  It did not seem to be dyspepsia or a gall stone or other common problem.  She also seemed to have a sadness about her that was hard to pin down.  We thought she might be depressed and called in the medical director to find out about options for possibly treating and following up on this.  The director picked up that she was more comfortable in Quechua and elicited that she had been told she has incurable stomach cancer and she just wanted to get some pain relief.   Apparently she did not know enough Spanish to tell us all this and we had lost something in translation.  One of the first questions we asked in triage was regarding language and need for translators but she apparently felt she would be able to communicate adequately in Spanish.  Another lesson learned – instead of asking patients if they spoke Spanish, maybe ask them if they would prefer to use Quechua!  Medical diagnosis is heavily reliant on history taking and this case again highlighted the need for open and excellent patient – physician communication.

Overall both the students and faculty members were getting more comfortable with the workflow and more efficient.  At times I would be working with 3 students simultaneously – one taking history, one doing an examination and one doing counseling and education.  Sabrina when she was not helping in ophthalmology would come over to help with the history taking in medicine.

Sabrina translating a case of back pain

She told me, “Medicine is so cool!  It is like a mystery you are trying to solve by talking to the patient.”  I am glad she was able to get this insight so early before being dazzled and brainwashed by hi-tech and low-talk specialties.

Soon it was time to leave.  Luckily all patients were seen by the time we left and so we did not feel guilty about leaving a bunch of work for the others.  Greta, one of our colleagues was going to accompany us on the same train so along with her we did our goodbyes and hugs and left in our cab.

Puma shaped mountain

The cab driver spoke only Spanish but between Greta and Sabrina we got a lot of information from him about the sacred valley.  He showed us a town with a Puma statue in the center.  The town is named after a Puma because the mountain next to it is shaped like one!

We picked up our back packs from the La Quinta Eco Lodge, said goodbyes and thanks to Edwin and the staff there and then drove on to Ollantaytambo.  Ollantaytambo is a beautiful town and if your schedule permits, allow some time to explore it.

Cafe outside Ollantaytambo station

Stream runs next to the street going to the train station

Also for some strange reason, the handicraft shops next to the train stations have some of the best prices compared even to the ones in the Pisac Mercado.  There is a decent waiting room inside the train station but it can get very full at times.  Instead if you need a place to sit, there is a great cafe just outside the train station gates which serves good coffee and also has pizzas made in wood-fired ovens.

The trains work very much on schedule and are very nice and comfortable.  Most of the people taking these are tourists and thus you have opportunity to meet and strike up conversations with people from around the world.

Train coming down track adjacent to where we are standing

We had one brief scary moment.  We were lined up to enter our coach when another train came in.  There is no raised platform so the only thing separating from being crushed to death was a yellow line in on the ground.  The train did come in very slowly and the officials made sure everyone stayed behind the line.  Still a pretty scary moment!

The train ride itself was quite uneventful.  It was dark and there was not much to see.  Next to me was a couple visiting from Australia whose daughter lives in Peru.

Note luggage rack behind me that served the whole coach

So we had a great conversation about Sydney and Peru and US and India and time passed quickly.  At the train station a person from our hotel was waiting for us with a sign.

We reached Aquas Callientas as night was falling.

It was dark and getting cold.  We followed him on a brisk uphill walk to the hotel glad that we did not have large bags to carry.  We were tired and wanted a good nights rest before getting up early for a bus ride to the top, to get there in time to see the sunrise from Machu Picchu.  Aquas Callientes has many many places to eat and food is thus not a problem.  We were staying at Hotel Green Nature which has been recently refurbished.  There is WiFi but with poor reception in the rooms.  The bathroom is excellent with hot showers and they serve breakfast starting at 4.30 AM for those trying to make it to the first bus.  The owner speaks English and is able to provide information regarding bus and Machu Picchu tickets if you need.  Being a worry wart, I had called the hotel from the US to confirm our reservation and he gave me a 10% discount just for doing that!

There are two reasons to get up early for the first few buses.  One is to see the sunrise over Machu Picchu.  In June, this occurs right around 6.00 which means you want to be on one of the first 3-4 buses.  These first bus leaves at 5.00 AM and the subsequent ones as soon as they are full and take about 30 minutes.  The other reason is to be one of the first 400 people to reserve a spot to climb to the top of Huyana Picchu.  Either way you want to be at the bus station close to 4.45 AM or even sooner.  There are a number of people who come to Machu Picchu by morning train and leave that same day.  Getting up early can help you beat these madding crowds!  This will also allow you to most likely see Machu Picchu’s mystic side, shrouded by fog and clouds.  On the flip side it starts getting warm at around 10.00 AM and if you get there after that, you can avoid carrying an extra layer of clothing.

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Day 7 – These students “need no education” Lessons in professionalism in the Andes!

This was going to be a special bus trip.  At breakfast we were told that we were going high up into the mountains on the east side of the valley (opposite to Cusco) and it would be cold.  Everyone rushed back to their rooms to grab an extra layer of clothing.  We even grabbed our wool caps and gloves just in case.

As usual we picked up Dr. Morales and a couple of Quechua translators at Pisac.  They told us to keep our cameras ready as the views would be terrific; and they were right! After about 15 minutes, our bus went off the beaten path and took what looked like a small trail (was actually much wider but we did not appreciate that right away) on the edge of a huge mountain.  The valley on the right and the huge mountains around us made for an amazing spectacle.  The driver handled the numerous switchbacks with aplomb but we would all subconsciously lean to the left at every turn.  When someone leaned over to the right to get a photo of the valley, we would shout to tell him to get back in his seat!  A decision was made that we would wind up our visit by 4.00 PM so we did not have to navigate these roads at dusk.

We reached our destination which we called Chew On Tire (actually spelled as Chawayantire) located in a large bowl shaped valley much like Cusco with terraced farming and green pastures.  The school consisted of a train of rooms arranged around a stone flagged play area.  There was a big celebration planned that day to commemorate the school anniversary and also as a welcome reception for us.  The school kids were dressed in traditional clothes and did a number of folk dances.  Some of these were done in bare feet or open sandals on the cold stone surface.  Sabrina commented on how glad she was we were going to distribute shoes to the school kids.  Behind the school we could see cows grazing

and roaming freely.  The facilities were excellent and all the teams were able to work indoors.  This was good because there were a couple of showers that would really have put a damper on the proceedings on that very cold day.

We saw quite a few patients.  I was surprised to see that no one had hypertension (blood pressures were in the 100/50 range for a lot of adults!).  No one had symptoms suggestive of diabetes.  We used urine dip sticks to check for sugar that day as we had left the strips that go with the glucose machines back at the hotel.

One younger adult came in with a strange complaint.  He had stepped on a nail a few months back and now thought his entire leg on that side was numb or dead.  The exam was completely normal and his symptoms did not fit any medical diagnosis.  We wondered if we were losing something in translation (he did speak Spanish which my medical student was fluent in) or whether this was a cultural issue.  We could sense he was unsatisfied when we could not find an answer to his problem.  Another patient we did pick up a distal neuropathy in the stocking distribution.  Her urine glucose was negative and we guessed she might have B12 deficiency possibly from Giardiasis.  We treated her empirically with albendezole which we had brought with us.

The lines were long and we had planned to leave by 4.00 PM.  This meant we had to start winding up by 3.00 – packing our supplies, carrying them back to the bus and loading them on the room rack, saying good byes etc.  Some of the patients after seeing the medical team  had made it to the ophthalmology and pharmacy area and had been waiting there for a long time.  No one wanted to tell them they could not be seen.  On top of it the local folks had cooked soup for us and it would be very rude not to at least taste it before leaving.  No one wanted to sit and drink soup while there were patients waiting to be seen.  The problem was solved by splitting up.  Some of us made several trips back and forth loading up the supplies.  The ophthalmology team continued seeing patients till they were all seen and a small group had soup with the local folks to make sure they did not feel offended.  We were able to leave only about 30 minutes after 4.00 and there was still sufficient light to drive safely.  I will remember the very strong feelings the students expressed about making sure every one was seen and no one was turned away!

The true essence of professionalism is putting the patient interest before your own.  We design curricula for teaching professionalism.  I am beginning to wonder if it is the doctors who need this curricula more than the students?  The students I worked with had these qualities already; when we put them in charge and removed the layers of bureaucracy and restrictions that are part of working in the US, they do the right thing and without having to be taught!  “They don’t need no education”

When the initial decision was being discussed to wind up while there were still patients in lines, our daughter had tears in her eyes.  On the way back our daughter kept asking, “we saw everyone right?”  She felt so proud that she was able to help so many people, some her own age and some much older and younger.  What happens to these sentiments as students make their way through the health care system?  They get wrapped up in the world of RVUs, the E/M codes, the CPT codes, lengths of stay and readmissions, tenure tracks and research papers, fighting over first authorships, using relative risk reductions (instead of absolute risk reductions and numbers needed to treat) to try and combat publication bias… Then we send them to curricula to re learn professionalism and how to improve patient satisfaction!  The lyrics of Pink Floyd were never truer!

 

Out in the remote wilderness of a mountain top in the Andes, I wondered what the US healthcare system would look like if we wiped the slate clean and allowed these dedicated, self motivated, energetic and bright young minds to redesign it.  They have no hidden agenda, no prior investments in a certain specialty, no huge fixed cost hospital buildings to maintain, no million dollar CEO salaries to support.  That day I had no doubt that it would be a better place we would go to!  Maybe it was the high altitude, or too much coca tea or maybe, just maybe I briefly glimpsed a vision of truth.  Is this why people sit on mountain tops to gain wisdom?

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Day 5 – Visit to a small Quechua Village

The team decided to start small, visiting a small Quechua village not too far from Pisac the central town for the district.  The goal was to do a pilot to get everyone used to the system and iron out any wrinkles.  It was supposed to be an easy way to get the mission started.

A genuine glass Coca-Cola bottle!

Our bus first took us to Pisac to pick up Dr. Morales and a Quechua interpreter.  This was to become routine every time we were to go to a Quechua village.  There was a hidden benefit of the Pisac stop – the small clinic there had clean bathrooms but even more important, there was a small shop across the street where we could pick up a bottle of cold Coca-Cola and return the empty bottle on the way back.  The price of the Cola – just 1/2 a sole!

Studying algorithms for managing eye problems on the bus.

On the way the students were going over material to help them in the clinic.  The ophthalmology group appeared best prepared with algorithms to manage common eye problems that they reviewed during the bus ride.

Soon the bus crossed the Rio Urubamba to and followed the west bank of the river to a small town set about 500 feet up the mountain.  The only way to get up there was a small dirt and gravel road with sharp hair pin bends.  The bends were too sharp for the bus to navigate and it stopped just short of the top.  We decided to walk up the rest of the way while the innovative bus driver instead of turning the bus just went straight at the curve and went up in reverse!

We made a human chain up some steps and as the bus backed up to the top, we passed all our supplies up to the school house.

The octagonal 5 station exam room!

There was one octagonal room that served as the exam room for all the medical cases and was shared by 5 teams of students and doctors.  There was not enough light here to check the vision and so the ophthalmology team set up shop outside in the sunlight. The pharmacy and shoes and education team sat on some steps under an awing.  This was my first taste of patient care on this mission and I was to get tremendous respect for the planning and adaptability of the medical students over the next 4 days.  They took everything in their stride and just kept going making the best of what was available.

Besides the facilities, the biggest challenge was language.  A number of the patients spoke only Quechua which meant we had an English to Spanish to Quechua and back translation going on.  Still we made good progress and saw everyone who wanted to be seen, taking staggered breaks for lunch.  The view was quite incredible and sitting in the sun on the mountainside eating our packed lunches we felt like we were on a remote outpost on a distant planet.

View from the small village school house

One particular case stands out from that day.  A lady about 2 months post partum after a normal delivery, presented with mid lower abdominal pain that started soon after labor.  She had no signs or symptoms of infection or bowel or bladder problems.  The examination showed marked tenderness below the umbilicus a little to the right of the midline.  We did a urine dipstick which was unremarkable.  We had very little else to offer and decided to send her down to Pisac to get an ultrasound (no other imaging modality available there) and some labs.  Some time later I was working with another student when another lady had a very similar presentation but this time going on for 2 years.  This too started soon after the birth of a child.  The tender spot was almost identical.  Seeing two similar cases back to back was clearly enough to get even our hypoxic brains thinking.  We asked the patient to contract the rectus by lifting up her head.  The pain got worse.  The tenderness was also worse.  This pointed to the source of the pain being in the abdominal wall rather than intraabdominal.

The cause of the abdominal pain

We recognized that this was muscular pain and the women carry their children on the back even walking uphill.  This requires the rectus to contract and leads to a rectus strain.  We were convinced we were on the right track and soon to prove the point, we saw 2 more women with the same symptoms!  QED!  That night we presented the case to the team after dinner and it was promptly labelled the “baby on the back syndrome!”  I talked to Dr. Morales to contact the first patient and get the ultrasound cancelled.

Soon we were ready to head back.  Everything had gone better than expected even though it was the first day of clinic.  No one wanted to take a chance with the bus on those hairpin bends, and so we walked down to the main road and boarded the bus there.

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Day 4 – Orientation to the Healthcare landscape in the Sacred Valley

I blogged about this at the official blog of the PHOP 

You can read all about it here.

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Day 6 – Seeing 270 patients at Arco Iris in Urubamba

This was going to be a busy day.  The local health administrators had put out a radio message inviting several schools to bring in their kids to our camp.  We were set up at a local school for children with special needs called Arco Iris.  We were able to walk to the school from our hotel but part of the way we were going uphill and several members of the group were low in oxygen when we got there.  We were carrying a pulse oximeter with us and our oxygen saturation immediately after the walk ranged from 82 to 95% with several folks having a heart rate in the 120 range.  A bit of rest and we set about planning our day. I will look back on this day as where I triaged young children (have not treated kids since medical school!), and then saw adult patients (the school teachers) and then went over to help out in ophthalmology (drawing on my ophthalmology residency experience in India).  But the most amazing memory will be of 13 year old Sabrina growing in confidence from hesitant Spanish translations to independently examining and treating refractive errors in school kids and even adults.  She wanted to write about her experience and here it is in her own words:

Status: Day 6 in Peru, Day 4 in the Sacred Valley, Day 2 of patients, Day 1 of being a doctor. This special day started with a nutritious breakfast of orange juice, bread w/ jelly & butter, and cereal with strawberry yogurt; deeeeeeelicious! After filling up with carbs the whole herd of medical students and doctors took an energetic walk to the school where they would be seeing patients. The mountains surrounded us and the view to the school was gorgeous.

We reached the school and started to set up. With no real background in medicine (except talking with my parents and helping my mom out with eye exams) the only reason I was there was to help translate the native Spanish speakers for the
doctors. I never imagined I would do so much more!

I helped with the eye clinic because the problems they had there were limited. I started out only helping to translate; a little here, a little there. But by lunch time I ran up to my dad and bragged, “I saw 15 patients by myself!” And I really had. It was so cool. I was able to communicate with them, take their vision test, give glasses accordingly, and prescribe the correct medication. Of course I would run it by my mother (the Ophthalmologist) but the majority I could do by myself. It was a great ccomplishment and a wonderful experience as I want to be a doctor as my profession.

But another one of my dreams is to do something with soccer; something I got to play with the native kids there. They were pretty good; really loved the sport! After that fun had ended, more fun was to come. I saw another bunch of patients. But there were so many of them! We stayed until almost dark because the line of patients was so long. My dad and some other doctors had to come in and help out because there were too
many! Thankfully, we got to see all of them and it felt so good to make such an impact.

We walked back as a group to the hotel. My feet ached and I was mentally exhausted as well. It was a real work out understanding the Peruvian patients, but also examining them and treating them was fatiguing! After a carb filled dinner, I had the energy to walk back to our room and crawl into bed. It was an impactful day.

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Day 3 – Cusco and the Sacred Valley

After our exhilarating and exhausting 12 hour walking tour of Lima, we left our hotel at 6.00 AM to get to the airport.  The cab driver showed up on time and there was no traffic so we made good time.  Since we left so early, we missed the hotel breakfast.

Check in went very smoothly.  We had our bottles of water which thought we would have to empty prior to security.  We asked the lady at the check in counter and she said, “Oh that is just for international flights.  No problem for domestic flights.”  She did emphasis that we should get to the gate as soon as possible, even though the flight was not till 8.15.

We went through security with our shoes on, and with our water bottles without a problem.  The screener was not even looking at the monitor as our carry on bags went through the X-ray machine.  Once we got on the other side we found only one place to eat with a very limited selection.  So at 7.30 in the morning we ate pizza and a chocolate croissant!  Looking back it would have been better to take our time to eat a decent breakfast before going through security as there is a big food plaza with McDonald’s Dunking Donuts, Subway, Starbucks etc.  Important lesson learned for the return trip.

Our flight was on Star Peru which has its own private waiting lounge area with several gates on the first floor.  It was great to see several of the medical students at the lounge as they were taking the same flight to Cusco.  Just a bit after schedule our flight was called and we got on a bus to take us to the plane that was on the tarmac.  When we got there, there was another bus parked at the plane and was unloading passengers onto our plane.  This was a bit confusing till we found out that the other bus has stopped at the wrong plane!  The passengers were asked to get off and we were able to board the plane!  I wonder if anyone would have picked up the problem if we had not showed up!

Passengers getting off after boarding the wrong plane!

View from the Lima to Cusco flight

The flight was remarkable for the amazing landscape unfolding below us.  The plane had to gain height very quickly as it had to clear the Andes.  The peaks at times seemed to be about to scrape the bottom of the fuselage.  We saw the very dry highlands interrupted by an occasional snow covered peak or a lake.  On the port side (North) were very tall snow covered peaks, with one particularly standing out from the rest.  This was probably the Salcantay peak which is over 20,000 feet and the plane appeared to be flying almost level with it.  Landing into Cusco was interesting as the plane had to find a low pass between the high mountains that surround the city and land and then dip down to land in the Cusco valley.

Cusco is at >11,000 feet altitude and I have to mention acute mountain sickness or Soroche as it is called here.  It can happen to anyone and it is good to be prepared.  Strangely the physiologic basis of acute high altitude sickness is still not fully understood.  A good review article from the Annals of Internal Medicine is available here.  At the elevation of Cusco, the barometeric pressure and the inspired oxygen are only about 70% that at sea level.  A rapid ascent to this height as in a flight from Lima to Cusco can precipitate acute mountain sickness with headache, nausea and vomiting being prominent features.

From “The physiologic basis of high-altitude diseases” JB West, Annals of Internal Medicine 2004; 141: 789-800

It is a good idea to start acetazolamide (Diamox) under the direction of your doctor, 24 hours prior to getting to Cusco.  This changes the pH in your blood towards the acidic side.  The body reacts to this by breathing faster and deeper and thus blowing off carbon dioxide.  This “hyperventillation” probably helps you get acclimated by starting early what you need to do at high altitude.  Acetazolamide does have side-effects most noticeable of which is strange sensations in the hands and feet and a loss of taste.  There are other options like high doses of steroids (with its own potential side effects) or local options like coca tea.  Almost everyone – even the fittest person – will have some shortness of breath and will need to slow down.

Apparently Acute Mountain Sickness usually does not start till about 2-3 hours after going to high altitude and does not occur at less than 9000 feet and.  Since we were planning to go down to the Sacred Valley (about 9000 feet) right away after landing in Cusco, we had not taken acetazolamide.  This was mostly because I have have seen people have pretty horrible paresthesias with it in the past.

At the airport we met up with the medical students and our minivan cab.  All the medical supplies and personal luggage meant we had tons of bags and it took a while to get all these loaded up on the roof.  We also waited for a couple of other students to show up on a subsequent flight.

It was about 11.00 AM when we were all ready to go.  We needed to be at our hotel in Urubamba at 5.00 PM for an address by Dr. Morales a local physician helping us coordinate the mission.

It seemed a shame not to explore a bit of Cusco since we were already here.  The cab driver was willing to show us around and stand by the minivan to guard the bags while we explored.

The Fiesta in Cusco’s central plaza

We had a terrific time in Cusco as it was Sunday and a day of fiesta with a lot of dancers and watchers congregating on the big plaza.  We drove up to the Inca Ruins and the statue of Christ on a mountain top (very similar to the one we saw in Lima).  Sabrina got to pet and pose with an alpaca.  We saw a Peruvian barbecue with families cooking in open fields with food being cooked underground with hot stones in a technique called Pachamanca – underground cooking.  I know I keep drawing analogies with Gujarati food (Tacu Tacu and Vaghareli Kichidi) but the resemblance between Pacahmanca and a very traditional Gujarati recipe called Matla nu Undhiyu is uncanny.  Both involve taking a mixture of green vegetables and tubers and roasting them with spices in a pot under the ground covered with fire.  Take a look at the links to the 2 videos above if you have doubts.

So far it had been a terrific day but we had by now spent about 3 hours at high altitude (that we had not originally planned for) and both Sangita and I got symptoms of Acute Mountain Sickness.  The features were typical with headache and nausea and we told the driver to start driving down to the valley which is 2000 feet lower.


On the way, he stopped at a very quaint “store” where they brewed coca tea for us and had Sangita inhale the scent of some fresh herbs and then put them on her head and covered it with a alpaca cap.  While Sangita was being ministered to, we got a demonstration of how natural herbs are used to color alpaca wool.


Coca Tea

Anyway, either the stuff worked or descending to a lower altitude did the charm for soon we felt better.  But Sangita felt it was the herbs that helped and she kept them in her bag for the rest of the trip, just in case.  We had to reluctantly throw these away when we got to Lima airport 8 days later so as not to get in trouble at US Customs!  

 Since we were feeling better, we stopped on the way to admire the view of the sacred valley and the majestic peaks before getting down to the valley.

View from Cusco to Urubamba

First view of Urubamba and the Sacred Valley

Soon we were in a beautiful sacred valley and pulling up at the serene La Quinta Eco Lodge which would be our home for the next 6 days.

Senor Edwin Gonzalez runs a tight ship here and supervises a very caring and professional staff for whom our every wish is a command.

We got a gracious welcome from Dr. Morales and enjoyed a great 3 course meal.  The amount of preparation that went into this trip was reflected in the fact that they did not need to be told about our vegetarian requirements.  The WiFi was working, the showers had hot water and the bedroom was huge.  We were all set to focus on our mission.

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Lima Day 2 – Walking Tour

We were very glad we had taken a day off to see Lima instead of going straight to Cusco.  That would have meant sleeping on the airport after a 7 hour flight which did not sound like a good idea.  Also it was Sangita’s b’day and we definitely wanted to make sure she had a good time! We had breakfast at the hotel consisting of Peruvian bread and jam and eggs.  There was also a crystal jar with thick dark brown liquid which looked just like maple syrup.  Imagine our surprise when it turned out to be very strong coffee!  Also it seems it is impossible to get regular milk in Peru – every time we tried to ask for it we got some very sweet thick liquid that was more like creamer! We were not sure how warmly to dress – it being winter but Lima is on the coast, and not too far from the equator.  We stepped out and found it very pleasant.  By 10.00 we were ready and right on time Alonso and Sandra our local Peruvian friends (guides) showed up. We had arranged for a 1/2 day walking tour with plans to spend the evening on our own. We started off by taking a short cab ride to Barranco which is a beautiful bohemian type suburb.  It is striking for its beautiful architecture with brightly colored buildings and narrow cobbled streets.  We were instantly transported to Europe!  We got our first experience of the Spanish plaza – which is such a fixture of all Peruvian towns. The bridge of sighs was cool – we had to hold our breaths while crossing it and our wishes would come true.  Sangita and Sabrina raced across the bridge while I sauntered across taking pics and holding my breath. I wished that we would all stay healthy on this trip – and it worked – well almost!  But more on that in a later post.   The bridge takes you to the first church which is pretty much in ruins.  The roof has caved in due to a previous earthquake and has become a home for vultures.  The facade is still brightly painted. A small path next to the church leads past small boutique restaurants and opens up to a patio overlooking the Pacific. The view is gorgeous and we were serenaded by musicians playing local tunes.  Lovely start to the day! Next we were to take a public bus to the center of old Lima.  For this we needed change.  I had withdrawn a few hundred soles from the ATM but it spit these out in 100 soles notes.  No one in Peru seems to have change for anything larger than a few soles it seems.  We ended up buying a toothpaste from a pharmacy to get the change. The bus plows a newly constructed central bus lane and is a very well run operation.  It is important to have exact change for the bus (I believe it was only around 1.5 soles. We passed the soccer stadium on our way and saw thousands of people wearing the same T-shirt as the one we picked up yesterday.  It turns out the next day was the day of a World cup qualifying match between Peru and Columbia and the whole city was going crazy about it.  The #6 jersey is worn by Juan Vargas their captain who also plays for Fiorentina.  Suddenly the T-shirt meant a whole lot more!  Coincidentally Sabrina was wearing the T-shirt today. Once we got off the bus in Old Lima, we made our way to the huge Plaza San Martin with a statue of Peru’s liberator Jose de San Martin.  On one side of the plaza there was a huge Coca-Cola display. Fans were pasting ribbons with good wishes for the soccer team.  These would be released like confetti at game time.  We also did our part.  As Sabrina wearing the #6 jersey was pasting a ribbon a local newspaper reporter sniffed a great story and took her picture for the local newspaper.  Sadly we left Lima too soon to see the newspaper the next day. The plaza itself is dominated by the statue and on one side of it is a 5-star hotel named after Simon Bolivar who along with San Martin liberator Peru from the Spanish. Next we made our way to the Plaza Major passing streets with exquisitely carved balconies.  These are supposedly a representation of Arabian influence on Spanish architecture.  Interestingly one can find very similar balconies in parts of India especially Rajasthan.

Courtsey TripAdvisor

These were designed so women of the royal family could look down into the streets without anyone seeing them. While the colors are different the resemblance is striking. Along the way we also visited a museum displaying the ceramics from various times in Peru’s history all the way up to the Waris and the Incas.  We also stopped at the San Francisco Convent which stands above the Catacombs.  The place is worth a visit for the some of the beautiful paintings and intricately carved furniture.  No photography is allowed inside. The next stop was the Muralla park where you can see the old walls of ancient Lima, a shanty town on a hill on top of which stands the newly constructed statue of “Christ of the Pacific” that resembles the “Christ the Redeemer” in Rio.

Pisco Sour

Tacu Tacu

By now we were famished and tired and we stopped for a bite to eat.  We had concerns about finding vegetarian food easily but this was not a problem.  We discovered that Peru has amazing varieties of potatoes and also discovered “Tacu-Tacu” which we fell in love with.  Needless to say, I also sampled my first Pisco Sour.  Pisco is Peru’s national drink and is >40% alcohol.  Pisco Sour is made by blending together Pisco with egg white and lime and topping it off with some cinnamon or bitters.  Peru is in a perpetual fight with Chile re’ where Pisco originated and who can claim rights to it! Tacu tacu is a mixture of lentils/beans and brown rice and served with salad.  It looks very similar to the Indian dish of Vaghareli (Fried) Kichhadi.  No wonder we loved it!  Since that first taste we looked for Tacu Tacu everywhere in Peru and luckily found that Bembos the local fast food place had it (just ask for the sine carne version). Altogether it was a great experience to complement a get Lima tour.  But we were not done yet! We did some shopping for Peruvian handicrafts and found a nice chess set with the pieces representing the Incas and the Spanish armies.  Finally we made it to the Plaza Major which has the Palace and the cathedral.  We were just in time to witness the changing of the guard.   It was already well beyond the 5 hours of “half-day” tour.  Alonso and Sandra had waited for us while we visited the Catacombs and also had eaten with us. We asked their recommendation regarding what else we could do on our own.  Since it was close to evening they suggested seeing the Magic Circuit of Water – the largest fountain park in the world.  Since it was quite close they graciously accompanied us to the park and we saw some amazing dancing fountains. After a laser show featuring popular Peruvian dances, we headed back to the hotel for a very well deserved rest and sleep.

We were incredibly happy to have experienced so much of Lima in one day thanks to our terrific Peruvian Local Friends.  We will always remember Sangita’s birthday!

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Lima Day 1

We arrived in Lima via United Airlines flight from Newark reaching late evening around 9.00 PM.  The flight itself was uneventful except for a couple of irritations.

  1. We were seated in the exit row but since Sabrina is only 13 she was not allowed to sit there.  We requested the folks sitting in the row ahead of us if they would be willing to switch their seats but 2 of them declined, “we are already seated, we don’t want to move”.  The third passenger traded his aisle seat for my window seat and Sabrina was able to seat close to us.
  2. United served a meal but it was chicken.  Being vegetarians we passed on this.  The flight attendant apologized saying, “We don’t have any special meals on this flight”.  It really is quite irritating that something that everyone can eat (non meat) is considered special but something only some can eat (meat) is considered regular.  Wonder if United will see some sense someday?  Won’t hold my breath.  They also did not have any of the snacks for sale.

Regardless, we reached Lima on time.  We had to fill out immigration and customs forms which were pretty straightforward.  Interestingly, the same folks who had refused to exchange seats, asked our help to fill out their forms!  Sabrina filled these out for them, and they thanked her, saying, “We did not know you 3 were together, otherwise we would have changed seats with you!”  The world is indeed a strange place.

One quirky thing about Peru is the difficulty purchasing anything online.  They require credit cards that are Verified by Visa or a similar MasterCard program.  Some will not take a card that is also a debit card.  So when I bought my Star Peru tickets from Lima to Cusco I could not pay for this.  I had talked with the customer service department  over the phone from the US and they would still not take the credit card over the phone.  They were going to hold the confirmation but we needed to pay for it at the airport the evening of our arrival.  So we tried to find a Star Peru representative.  We were told their ticketing counter was closed and would not open till 3.00 AM.  We were directed up to their office on the second floor.  The office had a sign stating that it was closed but they could be found at the counter on the first floor (where we had just come from).  Finally after a lot of searching we found a lady dozing at a small counter at the end of the lobby next to the rental car reps.  She took my CC and we were set!

Coca~Cola billboard

We had arranged for a cab to take us to our hotel in Miraflores and this was waiting for us.  He had a sign with our name on it.  He was extremely polite and even helped move our luggage to the parking lot.  We got our first glimpse of Lima with billboards displaying Coca-Cola and Samsung Galaxy ads.  All the cars in the lot were Japanese or Korean.

The cab ride reminded me of India.  The first 15 minutes took us through a somewhat “shady” area with stop and go traffic, honking and swerving back and forth.  Once we hit the freeway which runs along the Pacific coast, we moved fast.  We could smell the ocean and in the distance we could see an illuminated cross on a mountain top.  The ride took about 35 minutes and we paid 45 soles (15 dollars).   This is good information to have since this is the fair fare to pay for this trip.  It is OK to haggle a cab driver down to this rate if they ask for any more.

We reached our hotel quite famished.  We stayed at a small hotel called Miraflores Centro Suites.  As we approached the hotel we noted several chain restaurants like Pizza Hut, Papa Jones, Chilis, etc.  We were too hungry and tired to experiment.  We went to the Pappa Jones which was just across the street.  They had a great deal going – a family style pizza with a 2L bottle of Coca-cola and a basket of garlic bread for 32 soles with a T-shirt thrown in for free.  I think it was the T-shirt that clinched the deal.  We had no idea what it was but the lady at the counter told us it was of the Peruvian soccer team and Sabrina was sold.  Ordering the toppings on the pizza was a challenge.  Not one person in the restaurant spoke English (which were to find out was par for the course).  We pointed to the toppings in a picture of a pizza over the counter and finally got across that we wanted olives, mushrooms and peppers.  Sabrina had the option of a T-shirt with a # 6 or a # 9.  She could not get her favorite # which is 13.  So she chose the # 6.  The T-shirt was to make for a great story the next day!

We returned to the hotel, sent off a couple of e-mails and crashed!  Oh, but first we put the iodine tablets in our water bottles so we would have them for the next day.  The water was actually filtered and safe to drink but we did not want to trust this on the first day of the trip.

We had arranged for a walking tour of Lima with Peruvian Local friend at 9.00 AM.  We called them and changed the time to 10.00 knowing we really needed a good night’s sleep.

There was no A/c but we got a nice cool breeze from the open window and soon fell asleep!

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