Trip 6 – Apurimac

18th-25th October 2004

18 October 2004

This is to be the last DPP trip of 2004.  I was excited as always but sad it will be the last for a while.  The team was going to be made of 4 of us plus our driver.  2 volunteers flew in from the UK just the day before we left for the field.  They are mother and daughter – Jane and Elizabeth Blackstock.  Jane is a dentist and Lizzie was to be our assistant.  She has recently applied to Dental School, so I am hoping this trip will inspire her and not put her off!!  Marly Larabee is a Pediatrician from the USA.  She had been to the Apurimac in May 2004 and was returning to hopefully continue the work that was started then.  She would be seeing her own patients as well as helping us as much as possible.

I had made all the plans for this trip during the previous trip – or so I thought!!  I had arranged that we would have the Ministry of Health truck as usual and Fabian as our driver.  We planned the communities we would visit and I was assured that the Ministry of Health personnel would send radiograms to the Health Posts to inform them of our visit.  This I thought was straight forward…..

So when I called the Director of MINSA on Saturday 16th to confirm everything, to say I was surprised to hear he knew nothing of the trip is an understatement.  To make things even worse, he was boarding a plane to Spain for 15 days.  He could not help me!  He gave me the cell phone number of his “stand in”.  I thought this would be ok and we could sort things out – but when I called the number, I was informed it did not exist.  I called the director back but he was on the plane with phone switched off.  To keep the story/saga short, let me just say that many phone calls and stress later I finally speak to Fabian on Sunday afternoon.  He informs me that “Yes everything is organized for the 18th of NOVEMBER”.  My heart stop momentarily.  I gathered my thoughts and then explained that the trip is for 18th October – tomorrow!  Fabian was surprised and then realized the urgency of the situation.  We could not do anything on that day – Sunday, but planned to contact the doctora first thing in the morning.

I called at 7.30am and spoke to Doctora Gloria.  I explained the situation and she told me there were procedures that had to be followed and that she would call me in 2 hours.  Again, I will try to keep this short.  Basically I had to write an official statement of my purposes and objectives and once signed, fax it to her.  Then, with paper in hand, she could release the truck.  But she would not send Fabian, but Virgilio in his place.  My pleading requests for Fabian were in vain.  And so at 1pm, Virgilio was dispatched to collect us in Cusco.  This is a 3 and a half hour drive.  So he arrived at 4.30pm and after some delay in Cusco, we finally set off at 6pm!

We got as far as the city of Abancay.  It had been a nerve wracking journey in the rain and then in the thickest of fog over the high 4,000 meter passes.  We were all exhausted, especially Virgilio so we found a hotel and crashed there for the night.  I knew we still had a long 6 hour drive in the morning before reaching our first Health Post to work.  This delayed start had set us back and so we would make up for it by setting off at 4am in the morning!

 19 October 2004

I was up at 4am and went with Virgilio to fill up with petrol for the trip.  Then back to the hotel and we were loaded up and on the road by 5am.  We made very good time and arrived in the town of Chucibambilla at 8.30am.  This is the largest town in the region of Grau.  It has a hospital and we stopped there so I could speak with the doctor.  He was very friendly and efficient.  He assured me that he had sent out the radiograms yesterday and so the five health posts knew we were coming and would be prepared. 

This is the first trip I have done to Grau.  It is one of the 7 regions in the Apurimac department.  So everything was new to me.  The scenery was beautiful and incredible.  I never cease to be amazed by it.

We arrived at Santa Rosa, our first community, at 10.30am.  We were met by Rolando the lone tecnico working there.  He knew of our visit and had already passed the word to the surrounding communities and local schools.  So we got set up and started work just after 11am. 

We worked right through until 9pm at night.  I could tell the team was going to work well together straight away.  Jane and I worked with the patients while Lizzie took sole command of the instruments and sterilizing – as well as the important job of supplying us with the odd cup of tea to keep us going.  Marly was very helpful with translation from Spanish to English for Jane and also helped Rolando with “crowd control” and medication distribution.  She was also treating her own patients and saw about 15 that day.

We worked until 9pm at night seeing about 100 patients.  The majority were children that came from a number of nearby schools.  The children are so beautiful.  Many had never seen a white person before and so they were very curious.  They crowded into the health post to wait their turn.  Thank goodness Rolando could keep things under control.

There was one teenage boy who had a very swollen “geographic” tongue.  He had a fungal infection on it too.  It was quite uncomfortable for him so it was good to be able to treat that as well as his tooth ache.

We slept the night in the Health Post.  There were only 2 beds.  So we all squeezed in and Marly slept on an examination table.  We were so tired; we quickly ate some pasta and fell asleep.

20 October 2004

This has got to be one of DPPs busiest days.  We got up early after quite an uncomfortable night in the hospital beds.  We were on the road to our next Health Post by 7am.  It was a short drive to Pataypampa.  From the moment we arrived I knew this was going to be a good place.  We were met and warmly welcomed by the doctor (Jessika), nurse (Liz) and tecnica (Gabriela).  They gave us a quick tour, including the hospital where there were 4 new beds and which would be our “home” for the next few days.  We were all pleased to see it would be more comfortable than the night before!

We unloaded and got set up.  All the staff were keen to help and so they took charge of registering the patients, medications and toothbrushes.  This was a great help and I did not have to worry about anything as they were very able and efficient.  We started work at 9.15am and worked through until 9pm again.  We saw a record 166 patients!

For most of the day, Jane and I worked at a steady pace.  But when it got dark at 6pm we seemed to step up a gear as the crowds were still big in number outside.  Marly and nurse Liz helped a great deal and we were numbing patients and seeing another one while waiting for the anesthetic to work.  Music was pumped from somewhere all day and this kept our spirits high.  By the end of the night we were working like a “well oiled machine!”

Late in the morning we had 100 patients waiting when a school of 60 children arrived.  They had walked 3 hours to get to us.  I could not turn the children away so I did a screening outside and committed to seeing all the children who needed treatment.  The screening is always fun as so many people crowd around and they get closer and closer until I cannot move my arms.  Almost all the children needed treatment.  They had to skip the queue in order to get back to their village before night.  So I told the people waiting that if we could not see them today we would come back on our “rest-day” and finish treating them.  This calmed the crowds but still people were scared they would not be seen.

The children were great.  Hardly any cried or complained.  It was a pleasure to treat them.  I think the boys were having a contest of bravery as not one of them showed any fear.  Apart from one little 6 year old boy – Washington.  He was one of the last boys to come in.  There was a lot of pressure on him to be brave, and he was.  But I could see in his eyes that he was very scared and close to tears.  I spoke to him and we kept eye contact throughout the treatment.  His stare was very intense and I could feel the trust he was putting in me not to hurt him.  The extraction went well, without pain.  I had such admiration for this little boy; he had me close to tears!

A very nice family came.  The mother was 2 months pregnant.  She told me she had 2 children, one was with her, Edison but the other was in a hospital in Cusco with brain damage.  She had an abscess on her upper incisor that was giving her a lot of pain.  She wanted it extracted but was very concerned about her unborn baby.  She was terrified of causing any damage to this child.  I reassured her that it would be best to extract the tooth to avoid a greater infection and thus pain and stress to her and in turn to the baby.  So I did the treatment and it all went well.  But her wee boy, Edison, was screaming and scared to have his extractions.  Jane and I both felt we wanted to help this family as they seemed to be struggling with things.  So we spent a lot of time with Edison and even used another patient (a woman) as an example for Edison to see the extraction would not be painful.  Eventually, he had his treatment without a peep.  We all felt we had helped this family more than just extracting their painful teeth. 

Lizzie pulled her first tooth!  She has applied to Dental School and so she was keen to get some “hands on” experience.  It was quite exciting and she did very well!

My eldest patient of the day was a tiny 68 year old blind lady.  She wanted 8 of her lower roots extracted.  They badly needed it as there were numerous abscesses.  The treatment went well.  She was so grateful and sweet, I remember thinking “I hope you have some nice grandchildren who love and care for you”. 

In the early afternoon my right hand started to hurt and blister.  Luckily Doctora Marly came to my rescue with some moleskin – a life saver.  And then, not 15 minutes later I needed her again as a piece of tooth flew into my eye.  She got it out and cleaned me up – phew, what a relief!

As well as treating me twice, Marly saw 17 child patients.  She was busy throughout the day helping Jane with translation, giving tooth brushing demonstrations and playing with the kids.  It was really nice to have her support.

 The last patient of the day was the Tecnica.  She needed her upper right premolar root extracted.  It took me 15 minutes to get it out.  I just had no strength left – but eventually it came!  Then we all got packed up and fell into bed – exhausted!

21 October 2004

We got up at 6.30am and had breakfast outside in the sun – what a beautiful day and Pataypampa is in such a lovely spot.  The truck was packed up and we were off at 7.30am.  The 40 minute drive was spectacular.  The views of the mountains and river with the bright blue sky was magical.

We were met at the Health Post in Virundo by the nurse, Delia and tecnico, Jose.  They were very welcoming and gave us hot drinks and offered their help in any way possible.  So we got to work!

We saw an amazing 131 patients and this was only possible due to the team working so well together.  Virgilio, our driver, took charge of the medications and toothbrushes.  Jose took names and Marly was head of “crowd control”.  We had another big school arrive from a distant community and so she organized them for me to do the screening.  Lizzie had the sterilizing and tea under control and that just left Jane and me to get to work! 

Again the children were just amazing.  So well behaved and brave and polite.  Hardly any of them even whimpered – except for one!  A beautiful wee 5 year old girl.  Her entire deciduous dentition was carious.  Every tooth was decayed.  But at the very least she needed the 2 upper incisors and one lower molar out as they were abscessed and painful.  To give anesthetic to anyone for the upper incisors is painful, but for a 5 year old, it really hurts!  She screamed.  It was a heart stopping scream that had us all close to tears.  But Jane did excellently and got the LA in and the little girl was completely numb.  But she continued to scream.  So I took her hand and managed to comfort her and stop her screaming.  She held my hand very tightly and looked straight into my eyes.  I turned to tell Jane she would be ok to do the extractions, but Jane was crying.  She was upset by the screaming but also by the desperate state of this tiny girl’s mouth.  And there was no other choice but to take the teeth out.  So I did the extractions and she did not feel anything (thanks to the good anesthetic).  I was so touched by Jane’s reaction.  It just shows how much a person cares when they are reduced to tears by someone else’s pain.  A very special person.

Marly saw a little boy with a cleft lip and palate.  Luckily there is a team of plastic surgeons coming to Cusco next month from the USA - Interplast.  So she gave all the information to the mother and we hope this little boy will be able to get to Cusco in order to have surgery which he otherwise will not get here in Peru.  We all have our fingers crossed for him!We knew we had a rest day the next day and so we agreed to see all the patients who were waiting.  This took us well into the night but it felt good to be able to see everyone and not turn anyone away.  We then had to drive the 40 minutes back to Pataypampa where we all slept like babies!

 22 October 2004

 Our rest day – what a welcome relief!  We were all so tired that we really did appreciate being able to sleep until we wanted to get up.  We were up and about by 9.30am.  Had breakfast in the sun and relaxed.  We took turns to wash our hair (always my priority on my rest day!).  Chatted with Jessika and Liz (the doctora and nurse).  They are such lovely people and so interested in the project and funding and when we are coming back.  Jane and I then took a wee walk through town and enjoyed the people and views.  In the afternoon it got cloudy and a thunder storm came in.  It was the perfect excuse for us all to get into our beds and read our books.  Doctora Jessika then came in with her lap top computer and we all watched a movie.  How very surreal considering where we were.  Then it was time to sleep – a perfect day!

 23 October 2004

 Today was another great day and we all felt more relaxed and less busy.  But by the end of the day we had seen over 100 patients again.

 One of my first patients was a little girl with a swollen, infected gland on the underside of her tongue.  It was not painful but was giving her problems with her speech and eating.  So I cut it off and sutured her tongue.  It bled an incredible amount, as I had expected, but soon stopped with the sutures.  She was laughing and giggling throughout the procedure and so happy to be finally rid of the growth.  Very rewarding.

 We had a few good laughs throughout the day.  One was when I told a woman to spit in the bucket and she got out of the chair, crossed the room and spat in one of our plastic boxes.  The box had supplies in it as well as one of my tunics.  And she spat all over everything.  Lizzie was in disbelief.  She questioned if she had just imagined it, but no, the woman had gotten a bit confused and had chosen to spit in our nice clean supply box rather than the bucket full of spit and rubbish next to her.

Another moment was when an indigenous old lady came in.  She only spoke Quechua and appeared very poor with ragged clothes and bare dirty feet.  We all got quite a shock when she produced a full set of dentures from under her layers of skirts.  Where on earth had she gotten them?  She wanted us to make them fit better.  Unfortunately we could not and so she shuffled out again mumbling in Quechua.

 Marly extracted her first tooth!  It was a lower molar and I loosened it a little bit but she did excellently well and got it out without any problems.  We agreed that with her experience of “handling” people, she was better equipped to extract a tooth than a lay person.

 Towards the end of the day as we were all getting tired, Jane got a wee boost when a young boy, after having two molar teeth out, turned to her and thanked her in English.  It is amazing how much these little things can have such a profound effect on us.

 Virgilio did a great job today by organizing and distributing the medications and toothbrushes.  And then, after a long hard day, he drove us on to the next village, Tortora, where we would sleep and work the following day.  We were told we could stay in the “Italian Mansion”.  It is a nice big house where some Italian missionaries have an orphanage.  The sound of an “Italian Mansion” got us all very excited but unfortunately we were to be disappointed.  When we arrived in Tortora there seemed to be some kind of party going on and the “Mansion” was full.  Nowhere in town had space but eventually Virgilio found us a room.  It was horrible!  There were only 2 beds, the bathroom was communal for the entire town (can you imagine??) and everything seemed dirty.  We had a good laugh amongst ourselves though, especially as Lizzie overcame her fear of the bathroom!  We squeezed into bed and slept until the first rays of light woke us up and we could leave!

24 October 2004

We woke to realize the “nightmare” that we slept in was not that bad with the sun shining.  There was a little patio outside with a parrot.  The owner was cleaning up after the party and it all felt quite nice after all.  We had our breakfast and walked the kilometer to the Health Post.  The town, Tortora, is in the most beautiful setting.  It is surrounded by terraced mountains and lies right on a very clean river. 

Unfortunately, our welcome at the Health Post was not very good.  The personnel were quite cool towards us and the obstetrician called a meeting to discuss our “objectives”.  This was very strange for me.  I have always been met with open arms and gratefulness for the service we provide.  So the meeting was very formal and I went along with it.  But eventually I had to just say that it was not very complicated.  With permission from the Director of the Ministry of Health, we were here to treat dental pain and infection.  We would be doing extractions and fillings (where appropriate) – end of meeting.

The nurse was very nice and helped us throughout the day.  He was from Tortora and clearly cared a lot about the people.  The problem was that the staff had not informed the people clearly of our arrival.  And so the morning was quite slow but patients started to arrive from far away later in the day.  One family had walked 20 hours to get to us!!  So we worked late in order to see everyone. 

As we were setting up after our “meeting” a lady appeared.  She was quite elderly and very tiny.  She came right into the room and came to me and shook my hand.  She told me she was the Health Promoter in the area and wanted to thank us, on behalf of all the people in the communities, for coming to their town and providing this much needed care.  She asked us to step outside as she had a gift for us.  She produced a beautiful bunch of flowers from her garden and presented them to me.  With this, I could not hold back the tears.

I had been feeling quite upset that our welcome was so cold and I was sad anyway that this was the last day of DPP for a while.  It was as if this woman had been sent to remind me why I am here doing this work.  It is for the people that really need it.  The Campesinos, the people that cannot get relief from anywhere else.  And it reminded me that I want to continue doing this work.  Because it makes a difference.  I looked at this woman and thanked her, sincerely, for coming to see us.  Her presence encouraged me to take a few minutes alone, outside, to appreciate the beauty of the country and the people.  To remind myself why I am doing this work and be thankful for the opportunities it has given me. 

I went back inside and we started work.  The first hour was riddled with difficulties.  After my tears, Lizzie bumped her head and cried, Marly was struggling with a head cold and Jane had three screaming children one after the other.  I decided we needed a break.  We had some tea and chocolate and I shared my thoughts about the lady with the flowers.  I told everyone that I thought they were wonderful for all their hard work this week and that it was clearly wearing on us all today.  So we needed not to push ourselves too much and just do what we could.

From then on we fell back into our team roles, helping each other and enjoying the work.  And we had plenty of interesting patients.

A 5 year old boy called Jon came with mobile lower deciduous incisors.  His mother wanted me to extract them to make room for the erupting permanent teeth but Jon was very reluctant.  The teeth were so mobile; I put some topical anesthetic on and told him he could extract them himself with his fingers.  I thought this would be a quick, painless and simple answer to the problem.  My mistake.  Jon sat next to me and began to wobble his teeth.  An hour later he was still there!  Eventually I sent him home with his mother to complete the task.

 I treated a 12 year old mentally retarded girl.  It was a pleasure to see the care that her mother and sister had for her and how well she was treated by the community of people.

A very sad 8 year old girl came for treatment.  She had lost more than half of the hair on her head.  She had no eyebrows or eyelashes and thus had infections around her eyes.  The nurse asked if we had any idea what could be wrong with her.  After a series of questions, we realized that it was surely a genetic problem as her father and sister had the same hair loss.  But the frustrating thing was there was nothing we could do.  We took photos of her and Marly is going to investigate a possible diagnosis. 

The best service we provided the entire trip was to a woman with a very dangerous swelling.  She could not speak Spanish but it was clear straight away what her problem was.  All her lower teeth (except 2 central incisors) were rotten down to the roots.  They were infected and embedded into her lip and cheeks.  The result was her entire lower jaw was swollen and this swelling was extending under her chin.  This woman had had this pain and swelling for 2 years!  But it was now getting worse and causing her problems with swallowing.  Jane and I agreed that we had to extract all the infected roots.  Jane got the anesthetic in and started to extract but the woman then wanted to leave and was refusing treatment.  I explained, through the translator, that this was a grave situation and we must treat her.  She answered that she had to return to the fields for harvest.  So I had her daughter come in and explain, again, that if she did not have this treatment she was running the risk of having her airway blocked and ultimately asphyxiating.  So we did the extractions.  By the time the woman left, I think she understood the seriousness of the situation as she was very grateful.

On a more cheery note, there was a baby came in.  It was only 2lbs when it was born and everyone had been worried for it.  And now, 2 weeks later it was 2lbs and 6oz.  Marly checked her over and she seemed healthy.  She was just so tiny.

We treated everyone that came and finished at about 9pm.  We packed up and headed back to Pataypampa to get a good nights sleep.

25 October 2004

We were up early again – 6am.  It was a 10 hour drive to Cusco and we needed to get back early for Marly to catch a bus to Arequipa and Jane and Lizzie to get to their Inca Trail meeting.  As we left Pataypampa, the doctor gave us an official “Letter of Appreciation”.  It was to say thank you for our service to the people of the communities.  Their show of appreciation was very much appreciated by us.

The drive back was beautiful.  We stopped in Chucibambilla to say thank you to the doctor for his part in organizing the trip.  While there, a nun brought in a tiny baby girl.  She weighed just over 2lbs.  She had been orphaned when her 16 year old mother died giving birth in a distant community.  She would be brought up by the nuns.  Marly checked her over and reassured the nun that she was healthy.  She gave her advice on feeding and was pleased to be able to help one last patient.

We made it back to Cusco just before dark.  We were all exhausted and pleased to get out of the truck.  It had been an excellent trip.  I am sad that it is my last DPP trip of the year but pleased to have been able to spend it with such a good team.