Thank you so much for taking time to look at our blog! We are a group of edical students who are passionate about training and in underserved areas. This January and February, we are in Peru, the Dominican Republic and Costa Rica internationally as well as locally in Flint and Lansing completing volunteer service, rotating in hospitals and clinics, and learning about international medicine and local underserved health care. We appreciate any time you take to read our reflections and any donations you might offer.

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Wednesday, January 29

Peru Update- Clapham

Day 13 (1/23/14- Thurs):

Today and the past two mornings from 7-12 am, I've went to a private clinic called Clinica Cayetano Herideria. It is called a clinic but it also has multiple ORs and also two inpatient floors (one for OB patients and one general floor). It also has multiple floors of sub specialty ambulatory clinics, as well as a 4 bed Emergency Room. Although it is in situated in a very dusty area of town, the building is distinctly taller than the surrounding structures and has an exterior of marble and emerald tinted glass. Inside is also pretty swanky. Mostly private rooms with private bathrooms on the general floor, I think there's 12 rooms on the general floor and 10 are private and 2 have two beds. OB floors is all private rooms, maybe 6. All the rooms have leather couches and flat screens on the wall. In the basement is every form of imaging apparatus that I know about, including a Siemens brand CT machine that from what I can tell by appearance only is the same model that Hurley has.

I've been following attendings who manage both inpatient floors as well as the ER visits. Most of the general medicine inpatients are not critically ill, most have either pneumonia or are surgery patients (a post-appy patient, a transurethral bladder tumor removal patient,and multiple ortho patients). The first two days I was there I followed an attending named Dr. Poma, who is in his 2nd year out of medical school. He doesn't speak English so it's been difficult to understand everything that's going on about of the time, but also no doubt is good practice to have medical themed convos in Spanish. It has been similar to my experience following a resident in the states, he gave me lots of mini lectures that were complete with drawings and tables and he pimps me about differential diagnoses from time to time, so I've actually feel like I'm expending a lot of mental energy to follow him around all morning. He was great to be with and, like I'm discovering is typical of Peruvians, is very generous. By the second morning he was inviting me and the rest of my group to dinners with him and excursions to the jungle with him. These kind of invitations at first were awkward because obviously we barely know these ppl but I am realizing that 1) everybody down here invites everybody they meet to things all the time and 2) that about 50% of the time ppl don't actually follow through with their invitations.

Then today I was sent with another doctor, named Dr. Vacilio, who was a bit older. Like in the states, different attendings have different personalities, so it was a different experience. He was less interested in teaching me, but also we had a lot more patients than the last few days so were pretty busy. He was pretty friendly and explained things in good detail to patients, but definitely was more "machisto" than Dr. Poma and other younger docs. I think this stereotype of Latin men is fortunately fading with my generation.  He would flirt hard and pinch and poke EVERY nurse as we went to the different floors, and then in front of a big group told me that when he was in medical school he would always date two women at one once. By American standards it was entirely over-the-top unprofessional, but nobody here really did anything more than roll their eyes and most just laughed at his jokes.

Another difference that I thought I'd mention is how medical care and medicine is paid for here.  Cayetano is a private clinic and it was very often that the issue of payment came up from a patient. Multiple times I observed a patient in the ER only complete a part of the work-up and take their prescriptions, lab orders, radiograph orders or results and leave to take these to another site to get care. An interesting example is a patient came to the ER with a head wound that he got the day before at his job in the mine a few hours from Huancayo (between Lima and huancayo is a large mining industry). The patient had a bandage over about a 4 inch wound in the middle of his forehead. In the ER, Dr. Vacilio looked at the wound and wrote him a prescription for lidocaine, a syringe, suture, a needle, and antibiotics. Then his sister that was with him ran across the campus to the pharmacy and bought all the things that were needed for Dr. Vacilio to suture the wound. Then he sutured the wound. Also, none of the ortho tools and implants for elective surgery are kept in house, but are ordered when a patient comes in that needs those things. For example, a man with a work injury that broke 3 metacarpals and one of his wrist bones was admitted and given a soft cast and pain meds for two days while the pins that were needed to surgically reduce the fractures were ordered. Another patient who was a seamstress was injured on the job by a needle breaking and lodging in her thumb was admitted in the afternoon even though her surgery couldn't be done til the next day. I tried to talk to Dr. Poma and Vacilio about why these patients were admitted when they couldn't have surgery that day, but unfortunately I never really understood a firm answer they gave.

Despite several differences, I am constantly struck by similarities. A twenty-something came in with back pain and was accompanied by his mom, who asked a TON of questions...which is exactly what my mom would do if I went to the ER.

More things have happened but I will have to write tmr.

Day 19 (1-29-14):

We've done a few things since my last update. Mostly my hospital experience has been at the same Clinica Cayetano that I've been at for these past two weeks. I've been going in from 7am - 1 pm and then going home for lunch. Then in the afternoon we have been doing different campaigns or going to an orphanage. The Cayetano clinic folks continue to be very welcoming. A woman who I believe to be some sort of HR director invited me to go with them the past two mornings on an excursion to the Judicial Office of Huancayo. This office, which I was told has 200ish employees, made a contract with Cayetano to come and do a bunch of health screening stuff on site, including physical exams, vital signs talking, EKGs for persons older than 50 years, a blood draw, and a vision exam station. I felt really priveledged to be invited since this wasn't really arranged by FIMRC. When we first got to the building and went to the basement area where the stations were set up there was a lot of court employees crowding the area and Initially the flow of people through the stations was really disorganized with people not getting the right paper work for that station and people skipping around the stations and not following the flow, which made for confusion and people having to wait around because others went out of turn. I jumped in with the doc who was doing physical exams, but I only stayed with him for about 30 mins because he was ignoring me and not involving me in the interview or exam. So I left that station and found a nurse I recognized from the Clinica and asked if I could help her with EKGs. And I'm pretty happy I did because she taught me how to place all the EKG leads and work the printer, and after a few patients I was running the EKG station. This was a good experience because I was able to talk to each patient that came in and enjoyed the conversations we had. I did that from 9-1 probably. Then today I went back for day 2 of Cayetano clinic at the court, but there were fewer patients and I spent most of the morning talking to one nurse about Peru in general, the Peruvian medical education system, public health issues in Peru, and the Peruvian health care system. It was a really great convo because I learned a lot. For example, she told me that there are not very many heart disease patients or diabetes or kidney failure patients in Peru and also that very few Peruvians smoke tobacco. From what I've observed in the hospital and in the streets, I believe her. She also told me about the people in huancayo having a high incidence of volvulus because the low atmospheric pressure causing lots of gas expansion in the gut. No idea if that's right, but I enjoyed the convo. Then she explained To me how the public hospitals Carmen and Carrion were for people who didn't work, or worked for small shops or manual labor jobs. And that Peruvian who worked for a bigger company Were automatically enrolled in the government insurance available in Peru, called EsSalud (in English, This is Health). These individuals had auto-payroll deductions and were able to go to any of the EsSalud hospitals in the country, hospitals which exclusively treated EsSalud patients. However, while EsSalud is better than no insurance (ie the public hospitals), but still isn't great (long waits, etc). Therefore, chains of private clinics and inpatient and even operative services have developed (like Clinica Cayetano), for which people pay out of pocket for quicker attention and more luxurious environments. I'm not sure if you can buy extra insurances that cover expenses of those clinics.

In the afternoon we have done a few different things. Twice we have given first aid presentations to the Huancayo Serenazgo, which seem to be like a neighborhood watch type group because they clarified that they aren't police, but they wear camo uniforms and drive around the city in labeled tanks. At first hearing that were supposed to do this, I wasn't excited because I recognize that we aren't really knowledgeable in first aid topics. But we spent a long evening making talks and posters about different first aid topics and it seemed like it would be okay. Then when we arrived at the site for the first session, the 40 some Serenazgo that were present stood in a ine and at attention. This made me feel even more inadequate, because how could we possibly teach these professionals anything? But, and I think to all of our surprise, they were all super engaged, asking questions, discussing their own experiences with rescuing people, and even taking notes during all our lessons. Then after about 2 hours of lessons, we took about 30 minutes of photos at their request and that was it. We did this session 4 times as a group so all the serenazgo were Able to participate.

Finally, we have spent two afternoons at orphanages.  One that was pretty big and had a big play ground. The other that was smaller, with only an indoor play area, and had fewer children and was specifically for children with HIV and a few of their siblings that didn't have HIV. Both experiences were simply running around for 2 hours without a break and entertaining small children that were hanging all over us begging to be spun around or lifted up or pushed on the play equipment.

P.S. Our family is simply amazing. The experience would definitely be worse without them. The seƱora is a cute grandma that dotes on everyone and we try our best to make her laugh with our jokes. She micromanages us like little kids, but it is with such affection that we don't mind. Like she tells us to tell David that he should sit in the front of the cab after he has climbed in the back, or to tell Danielle to go put socks on because the floor is cold, etc etc. They are a really tight family with all four apartments on their complex being occupied by their brothers and sisters and their spouses and kids.

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