Dental Project Peru Trip 3

05-12 August 2004

Thursday 05 August 2004

The team for the 3^rd Dental Project Peru trip was made up of 5 people.  Amit Mehta and Stuart Humphries are both final year Dental Students from Newcastle University.  They had been traveling north from Chile where they started their trip a few weeks before joining Dental Project Peru in Cusco.  Clark Kotula is our assistant as in the first DPP trip.  Our driver is Virginio who works for the Ministry of Health but whom I am hiring to drive for this trip.  And finally there is me – as always!

We meet at the house in the morning to load up the truck which has been sent from the Ministry of Health with Virginio.  Our first obstacle is the huge gasoline cylinder which is the back of the truck.  It is necessary to carry all our fuel with us as there is no opportunity to refuel in the field, but this means that our generator does not fit in the truck.  So we just have to hope that most places have electricity in order for us to carry out restorative work.

We set off from Cusco mid morning.  I had planned to drive to Tambobamba today and sleep there tonight (this is about an 8 drive from Cusco).  But en route we discover that our first destination for work is closer to Cotabambas (about 5 hours drive from Cusco).  So I want to change our plans, but we need to communicate with the personnel in both of these villages.  So when we come to the town of Chinchypucyo, we stop and ask to use the radio at the Health Post.  Eventually we get through to the Doctor in Tambobamba who agrees it would be better to sleep in Cotabambas so she offers to arrange this for us.  So we hope that she is able to communicate with all people involved so we are expected.

The drive is beautiful as always.  The sun shines on us and the sky is clear allowing magnificent views of the snow capped peaks and the  mountains unfolding before us.  As we descend into the Apurimac gorge the temperature rises so at the bottom we stop from some refreshments.  But we have to be quick as the mosquitoes are terrible there.  Back in the truck and the ascent of the gorge begins.  We are treated to the wonderful view of the 24 switch backs from the opposite side of the gorge.

We arrive safe and sound in Cotabambas about 3pm.  At the Health Post they are expecting us and assure us it is ok for us to sleep there.  There are no “visitors” beds, however, so we have to use the hospital beds.  This is ok, but the bloody finger marks on the wall were a bit off putting!

We pass the afternoon in the sunshine playing “spinning tops” with the local children.  I radio each village to confirm the dates we will be visiting them.  They all seem to expect us – which is a relief!  Dinner is noodles, then off to bed to be ready for our early start tomorrow.

Friday 06 August 2004

We set off from Cotabambas in the dark, at 5.30am.  It is two and a half hours to Chaccaro – our first village.  The road is the usual bumpy dirt track for the first hour and a half, but for the final hour it turns particularly rough.  We are probably the only vehicle that has used this road for over a year.  It is rutted and overgrown from rains and landslides.  Eventually we arrive at Chaccaro.  There is one nurse working there.  She is expecting us and has got the word out to the local communities.  She expects many patients!

We get set up in one room with two chairs to start with.  There are already patients waiting and Clark organizes them and the waiting list.  We get started and continue throughout the day with only a quick lunch break of potatoes that a lady brought to us.  Amit and Stuart start by working together but within a couple of hours there are enough patients waiting that they take a chair each and we see 3 patients at a time.  Stuart’s Spanish is pretty good and he manages well to communicate with the patients.  Amit did not speak Spanish at the start – but soon enough he had picked up enough to diagnose and speak with the patients – and both were getting to grips with Quechua.

There were many children that came for treatment.  While we were treating them inside, Clark and the Nurse spent time with the waiting children giving toothbrush demonstrations and dietary advice.  They all seemed to enjoy it!

We finished work at about 5pm.  But as we were packing up, already very tired, two patients came back who were bleeding.  I packed the sockets which worked well for one patient but the other, a young boy, continued to bleed.  I had to put 3 stitches in.  The sun had set by this time and there was no electricity.  So in the dark with only my headtorch to work with, I stitched the socket.  It seemed to take a long time and by the time I finished, I was exhausted.

It had been a busy day but Amit and Stuart, although perhaps a little overcome by this new and different environment, seemed happy with the experience.  There confidence had grown noticeably throughout the day both with the clinical work and the communication with patients.  It was a long drive back to Cotabambas and we all slept well that night.

Saturday 07 August 2004

Another early start and bumpy drive to the second village of Occaccahua.  The drive was quite spectacular as we climbed to an altitude of over 4,500m.  There was no vegetation, only llamas to be seen.  The morning was clear and we could see for miles.  This is one of the most rural villages I have visited.

We arrived at the Health Post which was run by one Tecnica.  She was a lovely lady and very well organized.  She had known we were coming and informed many of the surrounding communities.  We were met by a group of excited children.  These children too were very sweet.  They were all dressed in rags with dirty little hands and faces.  They were curious to see our equipment and eager to help us unload.  These children stayed by the Health Post all day waiting for their treatment and then peering through the windows after their treatment.  Clark and Virginio spent time with them giving toothbrush demonstrations.  The wee boys loved the toothbrush model!

I had an elderly lady arrive.  She was in a great deal of pain.  The root of her lower right canine had exited the bone and was now embedded in her lower lip.  The lip was severely inflamed and infected and was extremely painful to touch.  The tooth had been like this for over a year!  She wept while we tried to anaesthetize her.  But once numb, she relaxed which made treating her much less stressful.  I extracted the tooth and then noticed she had the start of a similar condition on the opposite side.  I explained that I was going to treat the other side before it got any worse.  She was happy and trusting with what I said.  This side needed stitches in order to close the wound.  She left like a different lady and was very grateful for the care.

Our friend the Tecnica made us noodle soup for lunch.  This was very much appreciated as we were very cold and hungry.  After eating we felt ready to work again.  The patients continued to come until about 3pm.  Many were dressed in beautifully embroidered traditional clothes. 

One of the last patients of the day was a 4 year old boy.  He had a very painful mouth.  His upper deciduous incisor had embedded itself in his upper lip.  (Very much like the case with the elderly lady mentioned earlier).  His lip was swollen and sore and he was unable to eat for the pain.  Previously, his father had taken him the long journey of 14 hours round trip walking to Cotabambas to have the tooth extracted.  But the dentist was unable to extract the tooth as the little boy would not allow him to do the treatment.  Today was a similar situation.  The poor wee boy was scared and in a lot of pain and even touching his lip sent him into a screaming and kicking fit.  The father pleaded with me to try to carry out the extraction.  This was very disturbing.  In the UK, a child with this type of problem would have sedation or general anaesthetic to avoid stress to all concerned.  But this was not an option.  I had little choice but to ask the father and Tecnica to restrain the patient while I did the extraction.  He screamed and fought throughout which not only prolonged the treatment but had me close to tears and feeling as distressed as the poor patient.  The father continued to want the tooth out as the boy had not been eating and he was getting worried for him.  So we persisted until finally I got the tooth out.  Immediately the tooth was out, the boy stopped crying.  I sat with him for ten minutes to try to comfort him.  We just sat and stared at each other and tried to regain our breaths.

As we were packing up for the day, we noticed a family working in the mud.  They were making abode bricks to build a new house.  The whole family were there – mother, father, grandfather and 2 little children.  They were all covered in mud.  It was so cold.  This was a sad sight.

Occaccahua was the most remote village I have visited and it was extremely poor.  But despite this, there was a positive feel to the place.  The Tecnica was wonderful and the patients were so courteous and grateful.  There was a definite feel of community spirit and I felt people cared for each other and looked out for each other.  The children were a pleasure to treat (most of them) and a lot of fun to be with.  The whole team felt the same way about this village and we were all grateful to have had the opportunity to care for these people.

Sunday 08 August 2004

We woke in Tambobamba.  We drove there from Occaccahua the night before and were very pleased to find a hostel which was very pleasant.  It had a beautiful garden and the people were very welcoming.  We were up at 5.30am and drove 2 hours to Chalhuahuacho.  I had planned to be here on a Sunday as this is market day and many people come from distant communities to trade their wares.  So we were expecting a very busy day – and we were not to be mistaken!  The people started to appear at 8.30am and we started work then and did not stop until the sun went down at 6pm.  There were literally hundreds of people outside the Health Post.  Unfortunately, the staff there were not very helpful as they had so many patients of their own.  This left Clark in charge of “crowd control”.  Not an easy job!  Tensions were running high as there was quite a mix of people.  This included indigenous campesinos who had walked for many hours to come for treatment.  These people were our target population as they have never seen a dentist before, will not the opportunity for treatment again and simply do not have any money to pay for treatment if they could every get to a dentist.  But there were also people from the market who were slightly better off and had money and means to get to a dentist if necessary.  But everyone wants free treatment!  So Clark had a difficult task of prioritizing who would be seen.  (We would see everyone if time allowed).

So this was a learning experience.  In the future, I will avoid these larger market towns and try to go directly to the poorer communities in order to reach the people that need the treatment most.

Needless to say, we saw many patients this day.  Everyone worked very hard.  By now, Stuart and Amit were only seldom asking for my help or assistance.  Their confidence and abilities were improving with every patient.  It was great to see.

We slept the night in the hospital beds of the Health Post.  This is never the most comfortable or pleasant option but we were all so exhausted we slept like babies.

Monday 09 August 2004

Our destination for the day was Tambulla.  It was only a 1 hour drive from Chalhuahuacho, so we got to sleep in until 6.30am!  The drive was beautiful but very barren.  We were climbing in altitude and it got very cold.  When we arrived at the Health Post the doctor and nurse met us and immediately I knew we were going to have a good experience here.  They were very motivated and helpful.  As soon as we arrived the doctor jumped on his motor bike and headed off to tell both the primary and secondary school children to come for treatment.  They had already informed all the surrounding communities we would be here today.  So throughout the day people arrived from all over!

The majority of patients wore traditional dress which was particularly beautiful.  They really seemed to take pride in it and were clearly very talented weavers.  Most people only spoke Quechua so we were please when the local health promoter offered his services as translator.  He stayed with us all day and helped also with sterilizing the instruments.

Again we saw over 100 patients throughout the day.  Stuart in particular had a challenging day with 3 consecutive patients requiring more than 12 extractions each!  And I was pleased to get the opportunity to do a few fillings!  The doctor and nurse were also busy because since people are walking all the way to the health post, they try to get as many things taken care of at once.  This included a lot of baby measuring and weighing!

Tambulla had a similar feel to it as Occacchua.  The people were very nice.  The parents showed a vested interest in their children’s treatment.  Brothers and sisters looked after one another.  And the waiting room, although jammed packed full of people, was relatively calm with all the men and women spinning their wool.

There was one little girl that almost brought me to tears.  She stood at the door to the surgery all day peering in at us.  This poor little girl had a terrible skin infection on her face.  Her entire face was covered in seeping, blistering sores.  She was suffering quite a bit of discomfort but yet she was the happiest little girl, playing with the other children and laughing and running around.  But her parents were very worried for her.  They pleaded with me to help her.  It broke my heart to be unable to diagnose and treat her.  The doctor had already tried a number of different courses of antibiotics but nothing had worked.  They were planning to do some tests and hopefully from the results, be able to appropriately treat her.  I offered to pay for anything that could be done, but the doctor assured me she would receive whatever treatment was available with her government allowance as a child.

We drove the long three and a half hours back to Tambobamba that night after a fond farewell from all at the Health Post.  Again, although exhausted, we felt so positive about the work we had done in Tambulla and the people we had met.

Tuesday 10 August 2004

Asacasi was our fifth village and was less than two hours drive from Tambobamba.  We arrived by 8am and were met by a small gathering of waiting patients.  The Health Post had a large bright room for us to work in which made a nice change from tripping over each other all day.  We got set up and the Nurse offered us some hot chocolate. 

Stuart, Amit and I enjoyed our hot chocolate – little did we know how much we would regret it later.  What we had not realized was, the hot chocolate was made from unpasturised cows milk (not safe tinned milk as is normal).  Stuart was the first to suffer.  Exactly 3 hours into the mornings work, I glanced up to see Stuart had broken out into a cold sweat and had turned a frightening shade of green.  I told him to leave his patient and sit down.  What a terrible shame.  He really was very sick and, despite trying to come back to work a couple of times, had no choice but to spend the rest of the day lying down in the back of the truck.

So we were down to two.  Amit and I worked the rest of the day.  Amit was particularly pleased when he had the opportunity to do a couple of fillings.  After so many extractions, it is a wonderful feeling to save a tooth. 

The school children came mid morning.  The teacher had them stand in lines outside with the arms by their sides, very still.  There was already a lot of patients waiting and we had to laugh at the thought of these poor children having to stand in their lines like soldiers for hours.  So Clark suggested to the teacher that the children could be told to be “at ease”!

My last patient was the nurse of the Health Post.  She had a lower right mesially inclined partially impacted wisdom tooth.  Basically that means a really tricky tooth to extract!  She told me that she had been to 2 dentists who had refused to extract it.  On examination I could see why.  This was definitely a case for xrays and minor surgery.  But she begged me to try.  I told her I was not happy about doing it and she must understand that I may not be able to get it out.  In which case she would have to go to Cusco for treatment.  But the end result was I struggled with it for a while both it eventually gave up its hold on her jaw and came out.  What a relief.

When we had finally treated everyone and got packed up the nurse came to ask a favor.  Could we take a mother and her very sick baby to the hospital in Tambobamba?  Of course, I would never say no but the only problem was, were to put them?  It was far too cold for them to ride in the back of the truck, so the nurse, mother and baby went in the front and the four of us squashed in the back.  It was a very “cosy” two hour journey back to Tambobamba but well worth any discomfort – the baby was one month old and had a very severe case of Bronchitis.  If he had not gotten to the hospital and been given IV antibiotics that night, he surely would have died.

Wednesday 11 August 2004

Stuart had gone straight to bed when we got back to Tambobamba last night.  And Amit had said that he did not want to eat dinner as he was not feeling very well either.  So first thing in the morning, I went to check how they were.  Not good.

Stuart was feeling better but very weak.  Poor Amit had been up twice in the night to vomit and despite feeling better now was very weak also.  We all decided it best that neither of them came to Choqueca but rather stayed in bed and rested.  So Clark and I headed off with Virginio.

The drive was a little over an hour, but unfortunately, the road did not arrive at the village.  We got about a mile from the Health Post and the dirt track turned into a very rocky, thin animal track.  There was no way to get to the Health Post but walk.  So we unloaded the equipment and repacked only what was essential for the day.  Some men came from the village to help us with the gear.  We all got loaded up and headed for the village.

The Health Post was very poorly equipped.  It looked like it had had all its furniture stolen.  It was just an empty shell.  But anyway, that meant there was plenty room for us to install ourselves.  Clark and I set up in one room with two chairs.  There were going to be quite a lot of patients and I knew I was going to need to be anaesthetizing one while treating another in order to see everyone in this one day.  So we got to work and the system worked very well.

All the school children came in the afternoon.  There were so many of them (over 150) that I had to do a screening outside to determine who needed treatment and who did not.  We gave every child a toothbrush and also a tooth brushing demonstration to them all.  They were very nice children and very appreciative.

There were 65 patients in total.  I had treated 61 despite feeling a little bit queezy throughout the day.  But with only 4 patients to go – the rath of the hot chocolate hit me!  To spare you the gory details, I will only say that after a short “break” after patient number 61, I struggled to treat the last 4 patients before being extremely relieved to be finished for the day.

The drive back to Tambobamba seemed very long.  As soon as we arrived I went straight to bed and slept (with a few interruptions) until morning.

Stuart and Amit were both feeling much better but still a little fragile.  It is clear that 6 days of such intense work takes its toll on you physically as well as mentally (hot chocolate or no hot chocolate).

Thursday 12 August 2004

It was a beautiful day when we got up.  We all agreed that it felt like a Sunday.  All we had to do today was enjoy the drive home!  And we did.  We slept a lot of the way and were all delighted when we hit the first piece of paved road since 8 days earlier.  Bliss.

We arrived back in Cusco in the daylight.  All very tired, dirty and pleased to have had such a wonderful, challenging and rewarding experience.