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.
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!
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.
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.
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.
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.