Nada mas

I'm home.

It's hard to describe how I'm feeling right now. I left for Peru not really knowing what to expect. What I found was a beautiful little community where life was simple, people were kind, and there was always the feeling that you were not alone. People were always there for each other, and the Santa Clotilde Centro de Salud was a perfect example of this. This place was special, not only because of the services it offered to the inhabitants along the Napo, but because it was supported and made possible by the inhabitants themselves. Everything was a group effort, from the smallest tasks to the biggest undertakings. It was a privilege for me to be a part of this, and my experience in Santa Clotilde has undoubtedly changed the way I look at healthcare and my role as a physician. It was overwhelming walking around my neighborhood today. From the jungle to the urban jungle, the difference in way of life is incredible. In the jungle, you learn that life can be simple and still bring great happiness. I miss Santa Clotilde already, and am already thinking of when and how I will be able to go back.

My last day in SC was nothing short of amazing. After clinic and the weekly general meeting on Friday, we took the boat to a place called Huiririma. As we broke off from the Napo, the water turned from brown to a shimmering black. Once we arrived in Huiririma, we took a stroll and then jumped in the river. The water was beautiful and cool, very welcome on a such a hot day.

Brian on the boat to Huiririma

Approaching Huiririma, the water is a beautiful reflective black

The dock

Some kids watching peanuts dry - I tried one while it was still fresh, it was delicious!

Mazato - a fermented drink made from yuca, traditionally chewed and spat out in a container later to be mashed

Fanning the fire under the mazato

Another tool in the mazato-making process

Beautiful Huiririma

On the boat ride back, we stopped at Manolo's family's chakra, a small farm on the bank of the river. We brought back corn, as well as fresh sugar cane to chew on. Once back in Santa Clotilde, I had my final serving of chicken and plantains at the polleria around the corner, accompanied by all the friends I would leave the next day. After a necessary party at the local discoteca, I went for a walk to take in the quiet serenity of Santa Clotilde by night. The stars lit up the sky brighter than I'd ever seen before, their light augmented by the hundreds of fireflies all around. A few short hours later, I said goodbye to Santa Clotilde and began the long journey home.

Thanks for reading, everybody. I was happy to share this experience with all of you, and wish you all the best on your respective journeys.

Adios,

Erik

Jungle Fever

It's been just over 3 weeks now in Santa Clotilde, and I've been reflecting quite a bit on the differences in how medicine is practiced here compared to what I see in the busy urban centres back home. 

For example, I've seen two patients now who came in with what I would consider classic appendicitis: right lower quadrant pain, fever, anorexia, nausea, vomiting, and specific tests on the physical exam very suggestive of the diagnosis (Rovsing and obturator signs). Both of them had parasites. One got much better after a course of IV fluids, pain meds, and anti-parasitics. The other didn't improve overnight and we proceeded to operate. Just goes to show that the differential diagnosis is a little broader around here.

Then there are differences that are a bit harder to swallow. About a week ago, a little boy who had been discharged after I arrived here came back. He was irritable with nausea and vomiting. He had a long medical history, born with a cleft palate that had been partially repaired. While his lip and nose were closed, his palate remained to be fixed. Meanwhile, this little boy was shockingly small for his age, weighing in at just over 5 kg at the age of 3. The assumption was that his cleft palate was making it hard for him to eat, and so he was malnourished. Without the ability to measure protein and electrolytes, that was hard to confirm. But Saturday he rapidly deteriorated, and entered a comatose state. He was unresponsive, with nonreactive pupils and gasping for air. All signs pointed to increased intracranial pressure, but without brain imaging we couldn't tell where that was coming from. Was it cerebral edema, or was there a tumor with mass effect? He died shortly thereafter. He was scheduled to go to Iquitos the next day.

Finally, I've been getting a crash course in Dengue. On call one night a 16 year old girl walked in with 3 days of fever, headache, widespread body pain, and now presented with nausea and vomiting. Her hematocrit was elevated with low-normal platelets. I admitted her with a probable diagnosis of classical dengue fever, and sure enough the following day her platelets fell and her hematocrit rose. Dengue can be fatal because it can cause spontaneous hemorrhage and eventually shock. There is no cure, only supportive treatment with IV fluids and tylenol to control fever and pain. We've had 6 or 7 more cases of dengue since then, which prompted us to fumigate. At 6:00 AM. Needless to say I've been bathing in deet since this little outbreak of ours. The trouble is, dengue mosquitos bite during the day, but then malaria mosquitos bite at night. So you're hooped 24 hours a day.

This week in pictures: 

The usual around here: chicken with fried green banana, served with mayo and Inca Cola

After almost 3 weeks, finally went for a nature walk! With the heat and the unrelenting rain, I hadn't had too much time to explore. Here's a view of the Napo.

The cemetery, on the bank of the Napo

Ants hard at work

The end of our walk brought us to a serene little area which turned out to be a fish hatchery of sorts - my first swim in Peru, much needed!

Walking back into Santa Clotilde

Panorama of the view of Santa Clotilde from the top of the 'mirador'

Remember Karl Lewis? He was the kid who came in with a nephrotic syndrome. He has responded extremely well to steroid and diuretic therapy, and now runs around playing all day. While he was extremely shy at first and didn't want to talk to me, he's warming up slowly and will now shake my hand. I'm aiming for a full conversation by the end of the week.

Before treatment

After treatment

Only a few days left here. Saturday I take the boat to Iquitos to start the long journey back home. Time has flown by so fast! Thanks for reading, and stay tuned for the last update before I head on home.

Happy new year!

Happy new year everyone!

Here are the highlights from the last few days:

For Dr. Toni's birthday, Dr. Brian bought her a pig. Yes, a whole pig. After the beast was slaughtered, I helped cut up the meat. It was still warm - so weird! The next day we had an incredible feast up at Toni and Brian's place, live music and beer included. It was a warm and beautiful day, and I'm sure a birthday that Toni won't soon forget.

Toni and Jefferson, our biologist, shaking a leg and checking out the band

Toni and Brian officially opening up the dance floor

Me figuring out how to use the panorama feature on my phone!

New years here was a lot of fun. I cooked up some spaghetti and meat sauce and garlic bread for the group, which was a big hit. Most of the ingredients, especially the beef, had to be brought in from Iquitos (thanks to Blanca, our obstetrician). Dr. Toni (a true Italian from the Chicago area) was thrilled. After dinner we decorated the dining area in the traditional yellow, had some champagne, and headed out to the town center for a huge party where neighbouring pueblos from the Napo congregated to bring in the new year.

Enjoying some post-meal dessert - Manolo, one of our lab techs, seems unimpressed

Panorama of the party in the town center

The most people I've seen in one place in a while

Happy new year, girls! Manolo, again unimpressed

Some interesting things I've noticed during my time here so far:

• Everybody checks the money: anytime you pay for anything and hand over a bill, it gets a good tug, a rub, and a once over to make sure it's real.
• Dancing: in North America we often dance in groups. Here, that's a big no-no. You go up to the partner of your choice, ask them to dance, and sit back down when the song is over.
• Cheers: arriba (glass up), abajo (glass down), al centro (glass in front), a dentro (down the hatch)
• Dolphins: there are actually dolphins in the Rio Napo (saw some when I was waiting for the Rapido in Mazan). Dr. Julio calls them bufeos colorados, and says that some people say that they swim up to shore and turn into gringos. This brings me to my final point, 
• Superstition: people here believe in spirits. For example, a spirit called the 'Tunche' haunts the jungle at night, whispering names and making sounds. I was also told once that I shouldn't sleep in the call room because there are phantoms there. 

Interesting medical case of the day:

A 15 year old girl comes in with a 1-month history of an itchy rash on her left shoulder and arm, running down the  distribution of the ulnar nerve right down to the pinky and half of the 4th finger. While a diagnosis of herpes zoster is tempting, she has no pain, only itch. Does the rash follow a true dermatomal pattern, or is it along a line of Blaschko? If it's the latter, lichen striatus is the more likely diagnosis.

Happy holidays!

The holidays here are a lot like they are at home. Lots of food, drink, and merriment. To my surprise, pavo (turkey) is as traditional here as it is in North America during the holidays. Vanessa and Carmen, two of the nurses here, prepared a turkey feast Christmas Eve for the gang. Stuffing and all, the only difference was that it was prepared with a spicy sauce made from chili peppers. And of course, Peruvian 'champagne' was served.

Vanessa and Carmen getting the turkey ready

Carmen carving the turkey

The first plate of many - at the bottom is a spicy mayo - like Quebecers, people in Peru eat mayo with everything!

After dinner it was time for the big Christmas event at the hospital. 300 children from the pueblo came up for mass, followed by special treats to be given by none other than Santa Claus himself (well, actually, it was me). Luckily it wasn't too hot that night, but that's not saying much. I was sweating bullets in that costume! I was very thankful for the cold showers when it was all over with. Handing out candy to 300 kids takes a long time!

Santa, in the flesh - what you don't see here is the large, and very hot, beard I wore for 2 hours

Christmas day was spent hanging out with the gang, cooling off from the heat with cold beer by the river. It was remarkably sunny and beautiful that day - check out the view:

Interesting medical cases this week:

This little girl was pushed from a tree onto a Chambira plant (used to make all kinds of things in this area), whose long spines pierced the skin of her back. She came in with respiratory difficulty. There was no evidence of a pneumothorax, but she had a segment of rib that moved in and out with her breath - sign of a rib fracture.

This is Karl Lewis - for 2 weeks he had been experiencing progressive swelling of his entire body. He had been admitted for almost 2 weeks a few months ago with a nephrotic syndrome (excessive loss of protein in the urine, reducing oncotic pressure in the vasculature leading to widespread edema). Unfortunately he had not come in for his follow-up appointment, and therefore did not complete his full course of oral steroid therapy. 

That's all for now. Tomorrow is New Year's Eve and I'll be cooking Italian for the group. I hope everyone is having a healthy and happy holiday season. Thanks for reading, and I'll be sure to post more updates soon!

Life in Santa Clotilde

Hi everyone. Sorry it's been a while since my last post, but iPhoto has been giving me grief and so photo uploading hasn't really been an option.

It's been just over a week here in Santa Clotilde, and I've had no trouble settling in. Let me walk you through a typical day:

- Wake up around 7:15
- Take a nice cold shower (the only kind of shower available, really)
- Have a little bread and instant coffee, then head down to meet the team for rounds at 8:00
- See some patients in clinic, finish around 2:00 or 3:00, then have lunch
- If there's a procedure or C-section to do, do it, otherwise it's siesta time!
- Dinner in 'la calle', or cook with the team
- Enjoy some Spanish TV or read
- Lights out at 11:00 (the power actually shuts off at 11:00 - good thing I brought my headlamp!)

I thought I'd use my phone as an alarm clock, but no need - the roosters roaming the grounds of the centro de salud are kind enough to make sure I wake up early.

From left to right: dentist's office, prenatal health clinic, and outpatient medical clinic

One of the offices in the outpatient clinic

Siesta time!

This little boy is climbing the tree for fruit - behind him the residence where Doctors Toni and Brian live

It rains here. A lot. At least once day, but often more like half a dozen. It's nice because it cools the air down a bit, and makes an afternoon siesta that much more pleasant. Temperatures fluctuate around 32 degrees Celsius or so, but the sun is hot and most people lay low until dusk. At night, the streets of the pueblo are busy with people riding their motorbikes, selling food, and going for walks.

Rain shots

Some interesting medical cases so far:

Burn from methyl violet, often used in dyes

Meet Carlos - suffered a head injury in the past requiring osteotomy, and now presented in status epilepticus - lumbar puncture revealed cloudy CSF, and a diagnosis of meningitis was made. He recovered remarkably with IV Ceftriaxone.

This gentleman shot himself in the hand by accident when out hunting. Dr. Julio fashioned a makeshift pin with a needle to stabilize the fractured 4th proximal phalanx, and the patient is now awaiting transfer to Iquitos for reconstruction

Hopefully iPhoto continues to behave, and I'll post some more pics and stories soon. Stay tuned for details on Christmas in Santa Clotilde and an exciting visit from a heavyset bearded fellow from up North.

The Heart of Darkness

Well, not really.

Boating deeper into the jungle up the Napo river, I couldn't help but feel like I was on my way to find Colonel Kurtz. The horror! No, the journey up to Santa Clotilde was beautiful, and I'll rewind a bit and tell you how I got here.

After arriving at the Lima airport a responsible 2 hours before my flight, I waited an extra 2 hours before I finally took off for Iquitos. A wild "motocar" ride later (kind of like a dirt bike with a cab in the back) I was at the vicariate where I was able to fit in 6 hours of sleep before my first boat ride. Before I left, I met a Quebecoise nun who was happy to speak some French for a while. She said she'd been in Peru for the past 50 years, and asked if I'd do the same. To be determined.

Motocar ride #1

The boat was packed, but I was sitting next to a very friendly 15-year old boy who had lots of questions about who I was and what Canada was like. The boat took me up the Amazon River to Mazan, where I would take another motocar to the port which services the Napo River. The road was so narrow that I almost cringed every time my driver passed someone, and he passed people a lot. I got to Mazan with time to spare before boarding the "Rapido" to Santa Clotilde, so I went for a stroll and bought some local eats: an egg sandwich, and a a rice ball stuffed with chicken wrapped in a banana leaf. Delicious.

The dock in Iquitos

Motocar ride #2: through Mazan to the Napo River

The Rapido! 

The port along the Napo River - I later found out that Peruvians eat green bananas with everything

Some friends I made in Mazan - they wouldn't tell me where they bought their popcicles

The boat ride up the Napo was beautiful. I slipped in and out of sleep as we passed endless jungle, with temperatures fluctuating with the passing of numerous downpours. You would sometimes see homes along the river with roofs made of dried leaves and children playing in the river, where we would stop and drop off a copy of what looked like the latest newspaper. And almost 5 hours after I left Mazan, and 48 hours after I left Montreal, I finally arrived in Santa Clotilde.

Docked along the Napo

That's all for now. Much and more has happened since I arrived, but technical difficulties with iPhoto have slowed me down a bit with the photo uploading. I'll post again in the next couple of days with updates on life around here and the first of many interesting medical cases!

First stop, Lima

Lima. After nearly missing my connection in Miami due to a one-hour delay in Montreal (took a while to get all the ice and snow off of our plane), I've arrived in Peru. As my dear friend Erin pointed out, this is my first time south of the Equator. But I'm not stopping here. I'm going to the Amazon.

Some introductions are probably in order. A little of the who, why, and where behind this little adventure. My name is Erik, and I'm a 4th year medical student at McGill University in Montreal, QC, Canada. Outside of my budding medical career I'm also an avid outdoorsman, cyclist, hiker, skier, and epicurean (I just really like to eat). I'm applying to family medicine this year, and look forward to starting residency in July. 

So why am I going to the Amazon? I've always been interested in global health, and last January I had the good fortune of meeting Dr. Videsh Kapoor. She is a (fantastic) family physician in Vancouver, BC, and also happens to be the head of the global health program at UBC. Between patients and on generous rides home from clinic, we discussed our interests, including my desire to take my medical learning experience abroad. Having lived in Texas many years and being (adequately) proficient in Spanish, she suggested that I go to the Santa Clotilde Centro de Salud. Naturally, I said yes. 

I'm looking forward to seeing what kind of difference I can make with the medical knowledge and skills I've acquired so far. I'm also keen to learn as much as possible about how medicine is practiced in a setting where the resources aren't as abundant as say, the Montreal General Hospital. And finally, I believe that sometimes you need to throw yourself out of your routine to develop as an individual, and sometimes, if you're lucky, you learn something interesting about yourself. In other words, I'm super stoked for this trip.

A little on Santa Clotilde. Santa Clotilde is located in north-eastern Peru, on the Rio Napo. It is accessible mostly by boat, and rarely by float plane. It is north of Iquitos, the nearest major city.

Santa Clotilde is the referral center for a chain of rural health outposts linked by the Napo River.  The territory extends as far as the border with Ecuador, downriver as far as Mazan, and includes a major tributary of the Napo, the Tacsha Curaray, as far as the village of Buena Vista. Santa Clotilde serves as the primary center for supplies, patient referrals, and logistical support. 

I'll be living in Santa Clotilde for just under a month, and can't wait to get there. The plan today is fly to Iquitos, where I'll be staying the night. Then tomorrow I'll be taking a series of boats to my final destination. Today I was greeted at the airport by Father Moe and Raul, who generously took me in and made me breakfast. Can't take your malaria pills on an empty stomach!

So here's the deal: I'm not much of a writer. I plan to take as many photos as possible over the next month, and I'll use the most interesting ones to share my story with all of you. As internet access is intermittent in Santa Clotilde, I'll post updates as often as possible. Thanks for reading, and stay tuned for updates!