DPP Volunteer Trip 1 – 2005
13-20 June
Day 1
We’re Back! This is the first volunteer trip of 2005 and it is going to be great! It is a special team (as always) and I am excited to get going.
There are only 4 of us on this trip. Clark is our driver and is well prepared after the mammoth “Preperation Trip” last month. He will of course also be doing the medications as well as taking charge of our Education Program!
Yesenia Yepez is a good friend of mine. She is a Cusco trained Peruvian dentist, graduated last year. She helped me do the Porter Day in 2004 and is excited to come out to the Apurimac region with us.
Sean Cash is a very good friend of Clark and me. I met him in 2002 at language school in Guatemala and we have kept in touch ever since. He is a trained accountant and works worldwide. But he came to Cusco from his home country of Canada to spend a month here and help out with the project. He is a very generous guy and has given a lot of his time and energy to help us make a DVD movie of the project. The DVD, amongst other things, follows this first trip of 2005 thanks to Sean’s filming!
And then there is me – but you know all about me already!
We meet at the house early on the morning of the 13th of June. We get the truck packed up and set off for the Apurimac. We followed a different route from usual as we were heading to the very south of the Cotabambas region. This in itself was an adventure because we were not entirely sure how to get out of Cusco!! But we found our way eventually and a few hours later were met by the magnificent sight of the Apurimac gorge.
The journey took a long 9 hours but we were kept entertained by a good selection of music and the great scenery. We were tired when we arrived in Haquira but were pleased to be welcomed into our lodgings by our old friend Dino who is the caretaker of the house we stayed in. After cooking up dinner we decided to radio the Health Post in Haquira to confirm the addition of our extra team member.....
Haquira is one of the largest towns in the region. It has a well staffed Health Post including a dentist. We do not work in this town but rather use it as a base for the more rural and outlying communities we service. During our “Preperation Trip” we met the dentist from Haquira, Lucia, and explained what our project does. She was very interested and asked to accompany us on a trip. I was delighted to get the support and involvement of the local dentist and so kept this fifth space free for her on the trip. So our first night in Haquira we radioed her to confirm we would pick her up at 6am the next morning to take her to Huancascca and Patan to work with us. But we heard bad news…..
Lucia tells us the doctor from the Health Post has taken his “Free Days” and has left her in charge of the Health Post. She was therefore unable to come with us. She was clearly disappointed and felt guilty for letting us down. But there was nothing she could do. There seems to be no reasoning with rules when it comes to the Ministry of Health. The majority of people we meet go out of their way to help us in any way they can, but sometimes we come across someone (like this doctor) who have little common sense with regard to the care of the people. Free Days and Paperwork are part of normal life and nothing seems to take priority over these – not even an annual 2 day visit by volunteer dentists!
So this was a disappointment for us. Yesenia and I knew that we would have our work cut out with a dentist short. Plus Huancascca (our first village) is the largest of our 15 scheduled villages and we knew there will be a lot of patients to be treated. But what could we do but continue as planned?!
Day 2
We woke at 5am – it was very cold but just starting to get light. We sorted the truck, siphoned fuel, had breakfast and were on the road by 6.30am. The drive was quite spectacular but the road was pretty bad. Clark did great and got us there at 8am. But there was no-one around. No personnel in the Health Post and no patients. This seemed very strange because they definitely knew we were coming. So we waited for a while and then unloaded the truck and got set up in the Health Post. It was quite strange to find the centre open with nobody there but we took advantage of the situation and made ourselves at home.
With still nobody around, we decided to make the most of our time and headed to the local school to do our first Education Talk with the children. We met with the principle and discussed what we would like to do. That being, do the talk 3 times. Each time to 2 classes, starting with grades 1 and 2.
So we started with the youngest children. The talk was so well received. The kids loved it. The idea is to teach the children what foods and drinks are good and bad for their teeth. We use a big, colourful felt board that my good friend, Marly Larabee, made for us. We show the children different (felt) foods and drinks and first ask what each one is and then whether it is good or bad for their teeth. The children all get excited and involved and shout out the answers. Then we choose one child to stick the food/drink to the board on the correct side – either good or bad for the teeth. The game continues and the children’s attention is kept by the interactive and fun nature of the lesson.
This game is followed by a tooth brushing demonstration with the big plastic mouth model and tooth brush. Again the children really enjoy it and learn from it too, I hope!!! During this demonstration, Clark came to tell us that a few schools had arrived and there were over 200 children now waiting outside the Health Post with their teachers. So we hurriedly finished our demonstration and headed back to check things out.
At the Health Post there were children aged from 3 years to 16 years all waiting in orderly lines. So I immediately got set up for the screening and started with the children who had arrived first. As I screened them, we realised the majority of children needed treatment. Yesenia got straight to work as I sent the patients in.
Once the screening was done, I joined Yesenia inside and started treating too. At this point we really felt the absence of the extra dentist. But we worked on and were blessed with very brave children who hardly cried or objected to treatment at all. As always, the little girls were braver than the little boys. (This is true in adulthood also!)
The majority of our patients this first day were children. Communication had obviously got to the communities and the schools but there was still no sign of any Health Post personnel. As it grew dark we saw our last patient of the day. And as we were making our dinner, the midwife from the health post appeared out of the dark. She had just walked the whole day from Haquira. She had had to go there in order to deliver some “important” papers. We found this unbelievable. She had known we were coming to work today and I had personally requested her assistance but yet she had left the health post, and us, abandoned with no note or explanation – all in the name of bureaucracy! It was a good thing we were all tired and happy with our days work so that I did not show my frustration with her. She was extremely apologetic and assured us she would help us the next day.
We were comfortable in the “Casa de Espera” which is the accommodation provided for pregnant women to sleep in while they await the birth of the baby. Luckily, there were no women using the beds!
Day 3
We were treated to breakfast this morning! At 7.15am we went to a house opposite the health post where the mid-wife had arranged for the lady there to cook us potatoes (of course) and fried egg sandwiches! A nice change from cereal and yoghurt. We had some fun with her guinea pigs that run around on the floor of her adobe hut. Sean was fascinated, as was the little boy who lived there when Clark picked up a baby guinea pig and put it between two pieces of bread pretending to have a true “Andean Breakfast”.
We headed back across to the Health Post to start work at about 8am. My first patient was a gentleman who needed a broken down upper premolar removed. Not the best case to start the day – it took me 15 minutes to dig out the root!! Then the children from the local school arrived – all 130 of them! So I started the screening, we were up to 75 patients requiring treatment by 9am! I really needed to get inside and start working so I gave Clark a crash course in “screening” and he took over while I got to work treating the children.
When I got inside I noticed Yesenia had not started work on the children yet. She too had a difficult case. Another gentleman, he required his impacted lower right wisdom tooth removed. She had been trying for over 30 minutes but it was not even moving. It required surgery, so we explained he needed to go to Cusco. We gave him the necessary antibiotics and painkillers – he was quite relieved to leave I think!
So we started work on the primary school children. We worked from 9am through to 2pm. I would have two children at a time. Numb one up and have them wait while I numbed the other and then treated them both. This is a good method as you can ensure enough time for the anaesthetic to take effect but make the most of the time while this is happening. The children were wonderful. It never fails to amaze me how calm and accepting they are. I explain what I am going to do, and the majority understand and allow me to treat them without objection or crying. But there are always a few (usually little boys) who are very scared and whom it is impossible to reason with. I feel so sorry for these patients as it is simple fear they are fighting with. They come into the room to see a strange white woman with yellow hair. She has a tunic, head torch, mask and gloves on and she tells him she is going to pull his tooth out. A completely alien experience for them. I think I would be scared too!! But I usually manage to calm them down and treat the majority of them.
The patient that I remember most clearly from this entire trip was Washington. He is a 6 year old boy who walked 3 hours with his father to have treatment. Clark brought him directly into the surgery when he arrived as he had quite an alarming lesion on the side of his cheek. On examination I soon realised that this lesion was caused by a decayed and infected lower left deciduous molar tooth. The abscess was so substantial it was draining through his cheek onto his face. I have seen a number of cases like this during my time in Peru, but never before in such a young patient. My heart went out to him as I realised the amount of pain he must have suffered and the treatment he was about to endure.
Washington had had this visible abscess for over 3 weeks and had been given antibiotics by the dentist in Haquira (Lucia) but it had had no effect. It was clear to me that the necessary treatment was removal of the tooth and incision and drainage of the abscess. But how would he cope with this? The answer – amazingly!
I gave him anaesthetic which was quite tricky as he could only open his mouth a small amount. I am sure it must have been uncomfortable but he simply sat and let me do it. When I was sure he was completely numb, I elevated and removed the rotten milk tooth. The pressure from this procedure resulted in a huge amount of pus exuding from the wound on his cheek. This was unpleasant to say the least….
It was a great relief to have the cause of the infection out. But I knew I had to rid little Washington of the contents of the abscess. So with scalpel in hand and bowls and gauze at the ready – I incised the abscess. Again, he was great and did not feel any pain. But as I proceeded to clean the site he started to wriggle and cry. I knew he was starting to feel pain so immediately stopped and gave him a direct local anaesthetic to the abscess site. This was very uncomfortable and it was difficult for me to put him through that pain but I did not have any choice. As a wee tear rolled down his cheek, I could feel them welling in my eyes. But I had to hold it together and get on with the job.
When he was numb, I continued to incise and drain the abscess. Once I had cleaned the inside of the abscess and irrigated with copious amounts of Chlorhexidine I closed the wound with 3 sutures. The final thing to do was clean Washington’s face where pus and blood had been caked on over the past 3 weeks. By this stage, he was becoming distressed but as I gently explained that we were all finished and just cleaning his face, he regained his composure and allowed us to dress the wound.
I managed to finish the treatment, but at the last moment I lost my composure and had to leave the room. I could not stop my own tears any more. How could this be? This little boy had suffered excruciating pain for not just 3 weeks but probably months. And now he had endured a surgery that most people, adults and children, deserve to be sedated for. Life here is hard and on these trips I am reminded of this every day. What would have happened if we had not been here? How long would Washington, and hundreds of others, suffer? My heart is heavy in moments like this but my motivation is fuelled. The project works and we must make sure it continues.
On regaining my composure, we finished treating the primary school children. After lunch we saw the children in most desperate need of treatment from the secondary school. And then it was the adults turn. They were very nice people. They had waited patiently all day while we saw the children. But we immediately realised why they had waited. Their mouths were shocking to say the least. The majority required multiple extractions and even clearances in some cases. There was an incredible amount of infection and these people had suffered pain for years!
Huancascca is the only village I had not visited before. Since those 2 days, I have realised that Dental Project Peru is starting to make a difference in the Apurimac. Every other village visited so far has had less cases of multiple extractions and full mouth clearances. This is because we treated a lot of these patients in 2004 and now people are generally returning for 1 or 2 extractions. Please do not misunderstand, there are still many patients with severely infected mouths that have never seen a dentist, but I feel that with each visit to these communities we are really managing to reduce the ongoing pain and suffering. I hope that when we visit Huancascca in 2006, the difference will be notable too.
We finally saw the last patient at 7.45pm and were cleared up and ready to eat and sleep by 8.30pm. And we slept well as always.
Day 4
Today was great – despite a frustrating start! We woke at 6am to get an early start as we needed to drive to our next village – Patan. Clark discovered our first problem – our ropes for tying the equipment into the truck had been stolen. Probably while the kids were waiting for their treatment, they saw the ropes and thought they would be fun to have! But we soon forget the ropes when we discovered the second problem – the truck would not start! The battery was dead. We got some help to push the truck out of the “garage” and downhill to try to roll start it. But with no joy. We were now running out of downhills and needed to think of other options. The Health Post had 2 batteries to operate their radio. So we tried both of this. The larger one started the truck – hooray. But when we put in our own battery the truck died again. The battery fluid had leaked out and would not hold a charge. So we filled it with distilled water and asked to borrow the battery from the Health Post. Our hope was we could at least get to Patan (our next village) and start treatment. In the meantime we could charge our battery there with their solar panel over the 2 day visit and then leave Huancascca’s battery in Patan for them to collect – and we would be set to go with our own battery. This plan was agreed to by the mid-wife (she owed us a favour after deserting us!) and was put into practice immediately. We packed up the truck. The principle of the school heard about our ropes being stolen so took the rope from the school flag and gave it to us to tie down our equipment. A nice gesture. And we were off!
The road between Huancascca and Patan is horrendous. We needed 4 wheel drive most of the way and had to go very slowly. But our truck is really great and managed without any problems. We arrived in Patan two hours later. The Technician at the Health Post said the village was having a meeting and were also announcing our arrival so the patients would be here soon.
This gave us time to deal with our next problem of the morning – no water in the village! Patan sits above 4,200 metres and so the spring which supplies the Health Post often freezes. So we jumped back in the truck with empty buckets and went to the river to collect water. It is just all part of the adventure…..
When we arrived back at the Health Post with the water, we were met by the sight of 198 children waiting outside. Time to get to work! I did the screening, Yesenia started the treatment, Clark did the medications and Sean kept up with the sterilising. A good team!
I saw two cleft palate cases. One was Esther, the 13 year old girl I treated last year. I waved to her in the crowd of children and she seemed very proud to be recognised. Unfortunately her dentition had deteriorated even more and I had to extract two more permanent teeth. She is an extremely happy girl and this in infectious to be around.
The second cleft palate case was a 5 year old girl named Elianita. She had had her cleft lip closed but not her palate (as with most children there). She had a decayed lower deciduous molar that would have been for extraction. But I decided not to do the extraction as she was clearly terrified when I went near her mouth. I suspect her cleft lip operation had been quite traumatic and she was scared of any doctor doing treatment in her mouth. The procedure would have caused further trauma for her and I felt the need for treatment did not justify this upset. She left with her new toothbrush, sticker and medications.
A 6 year old boy, Ruben, presented with a decayed lower right deciduous molar. But this was not our main concern. We noted a large (about 3-4cm) facial swelling. It was located under his jaw bone at the angle of his mandible. It was hard and hot. We struggled to get a history of the swelling as the boy only spoke Quechua and at the age of 6 could not recount the history. His parents were not with him and the teacher did not know how long it had been there, if it was getting worse etc. We noted the decayed tooth intra-orally but the location of the tooth and the severity of the caries did not correlate with the extra-oral swelling. We agreed we could not incise the swelling with no definitive diagnosis and so were left with only one treatment option. I extracted the decayed tooth, we gave the boy his dose of antibiotics and instructed the teacher to return tomorrow with the patient and his parent(s). We would then assess if the extraction and antibiotics had had any effect on the swelling and also get the history from the parent. With this information, we would hopefully be closer to a diagnosis.
Urbano, the technician in the Health Post has had some training in tooth extraction. So we worked with him, expanding on his training in Local Anaesthetic administration and techniques for extraction. He did very well and appreciated our guidance. He does not have any extraction instruments at the moment, so I hope to gather donations of either instruments or funds to buy instruments in order to give him the kit he needs to do these basic extractions he can cope with.
We worked very efficiently today. We treated almost 90 patients which was good considering our late start at 12pm and our finish time of 6.30pm.
We bunked down in the birthing room of the Health Post. Not the most comfortable lodgings but that did not stop us sleeping like babies!
Day 5
We enjoyed a morning of not travelling. I got up at 7am and attempted to wash my hair. But the water was frozen, so I put it in the sun and waited for it to melt. It was the most painful hair washing experience of my life! The ice melt froze my scalp and gave me a terrible headache – needs must though!
Our first patient came at 9am and it was constant from then on until 4.30pm. The secondary school came but one class at a time – which I thought was very considerate. They all had their treatment and were thankful for the care.
We were pleased to see little Ruben back with his mother. The extraction socket was healing well already but unfortunately the swelling had not decreased. In fact, it had possible increased in size slightly. His mother told us the swelling had appeared five days ago and was getting bigger with each day. We all agreed it was not related to the tooth and so decided Ruben needed to have a biopsy and other tests in Cusco. There were numerous possible diagnoses, but we were very keen to rule out a cancerous lesion. So we did not panic the mother, but stressed the importance of taking Ruben for tests. She seemed to understand the urgency but told us she could not take him. It was “chunio” time. This is the 10 days when the campesinos harvest their potatoes and naturally freeze dry them. This store of freeze dried potatoes is their staple diet for the entire year. I understood her commitments but had to insist her first priority had to be Ruben. Her family and friends could help with her harvest – but she had to take Ruben to Cusco. I organised the ambulance to take her from Haquira the following day. She told me she would go.
Our last patients of the day were 2 little brothers. They came to the health post with their older brother who was 10 years old. I watched as the older brother took care of them. He explained to them why they needed treatment, not to worry because the local anaesthetic would take away the pain, that we were doctors and would take care of them. He lifted them into the dental chairs, took their hats and then held their hands and comforted them throughout the treatment. Afterwards he ensured they got their medications and toothbrushes. I was so touched by the way he cared for his siblings. It is strange, but I rarely see this kind of affection and concern here – even from parents. It reminded me how strong and important the bond between brothers and siters can be. It was beautiful.
It was the father of these boys that had been charging our battery for 2 days. So once we were packed up, we collected the battery and rejoiced when it worked. We left the other battery at the health post and set off for Haquira. A two hour drive to comfortable beds!
Day 6
Our last village of this trip was Tambulla. I really like this village. The people all dress in traditional clothes and speak pure Quechua. There is a real feeling of community here and the health promoters are very involved with the health post. We arrived at about 8.30am from Haquira. The drive to this town is great – we literally have to drive up a shallow but active river bed. We got set up, but there was no water again. So Clark went on a successful mission to find some. We were ready to see the first waiting patients by 9.30am.
The personnel in the Health Post were very busy with their own patients so we employed the help of a local health promoter to help with Quechua translation. We worked throughout the morning mainly treating adults.
Mid-morning, a school arrived from a distant community. It was Saturday so I was impressed they arrived at all. The teacher was very well informed and keen to help with the screening and translation. I did the screening outside. It was so nice with all the children in their traditional dress. The level of caries was relatively low compared to some villages we visit. This is due to the remoteness of the villages and the lack of refined sugar in the diet. But there was still plenty of treatment required and infection to treat.
Unfortunately, the first child that came in for treatment cried. All the waiting children could hear this and thus a chain reaction occurred. Almost every child after the first cried before their treatment. They were obviously scared after hearing the cries of the first child. When this happens, it makes for a very stressful and tiring few hours of work. It is distressing for us as dentists to have upset patients and requires a lot of patience and persistence to get the treatment done.
During the morning, the teacher gathered all the children for the Education Talk. We had explained how to do it and he continued enthusiastically. All the adults gathered around with interest too which was great to see.
We stopped for lunch and were enjoying the peace and quiet when we heard shouts of “doctora, doctora”. Clark raced out to see what the emergency was to find a woman about to give birth. We could not find the doctor anywhere so Yesenia and I put gloves on and prepared ourselves to deliver the baby! Fortunately, at the last minute the doctor arrived and took control of the situation. The wee baby boy was born! He was perfectly healthy and Yesenia and I cleaned him and wrapped him in a blanket. The parents did not have any clothes or blankets for him – nothing. We felt so sorry for the wee thing but there was nowhere we could get any supplies as we were so far from even the nearest shop. The poor mother suffered terrible pain (as mothers will understand) and continued to suffer when the doctor told her she could not lie down in the bed unless they had brought their own sheets. The lady had given birth in the squatting position and was clearly ready to take the wait off! We sent the husband off to find a blanket or sheets so the exhausted woman could rest. Thankfully he returned shortly after and we got the woman comfortable. It was an amazing experience even though the actual birth was not visible due to the mother’s layers of skirts covering her to the floor. This is the traditional way to give birth in the Andes and many women still prefer to do it this way.
We finished for the day at 5.30pm. As we cleaned up we became aware of the crying of a little boy who had been taken in the day before. He had fallen off a rock and severely injured his face. He was lying in a bed in a storeroom (as there are no hospital beds in this health post). The cries continued and it became unbearable to hear him suffering so much. I asked the doctor if there was anything we could do. She said he was receiving all the pain medications that his government funded “child insurance” allowed. Quite clearly this was a minimal allowance. So I asked if we could buy him whatever intramuscular pain medication there was so that he could actually have pain relief. The doctor agreed and so the little boy received his meds and managed to sleep through the night. Again, we all found ourselves cringing at the day to day suffering people endure.
We slept on mattresses on the Health Post floor. It was very cold outside at such high altitude but we were kept warm by the closeness of our sleeping arrangements!
Day 7
This was the final day of DPP Trip 1 2005. Another good day but I think it was the most tired I have ever felt on a trip!
We were woken at 5am to the screams of another woman in labour. She had walked from a distant community in the night after she went into labour. Luckily we were not sleeping in the birthing room and she managed to give birth to a little boy by candle light (as there is no electricity).
We went back to sleep but were woken at 7am to lots of noise of patients and music! So we were up and working by 8.30am. I thought it was going to be a quiet day because of the market in the nearby town of Chalhuahuacha – but I was wrong! The patients came steadily all in their beautiful traditional dress. Even a school came with the health promoter in charge. This was surprising being a Sunday. There were 32 children in the school but only 10 came for treatment. They all seemed very scared and unfortunately most of them cried – with and without treatment!
The kids crying made the day very tiring. We had lunch at 12.30pm and the energy seemed to drain from me after that. Yesenia and I struggled to get back into it. Her arm was painful from extractions and my back hurt. We thought we would only have 20 patients in the afternoon, but more and more came. I think the Tambulla total was almost 200 patients!
I had a 5 year old patient, Monica. She had walked 4 hours to get to us without her parents. I extracted her abscessed lower deciduous molar tooth and she cried throughout. After the extraction she was ok but I could feel her tiny heart beating so fast! I picked her up and gently rocked her – she calmed down and then seemed quite happy in my arms. I was definitely happy to hold her and be able to comfort her.
Poor Yesenia had one little boy vomit all over her shoes. We think it was a combination of fear and anxiety but he could not contain himself. He turned a strange shade of green before depositing the contents of his stomach on Yesenia’s shoes and the surgery floor. Afterwards he recovered well but did not go through with his treatment.
Towards the end of the day, every extraction seemed difficult as we were so exhausted. It took so much longer to get this one upper molar out because I just could not put the strength behind it. My last patient wanted his almost horizontal lower left wisdom tooth taken out. I looked at it and knew I could get it out but being so tired I had to tell him it would be difficult and would take some time. The poor man was trembling with fear to begin with so this news was not exactly what he wanted to hear. But he insisted the pain was so bad that he wanted it out. But it all ended well, a last burst of energy from my weary arms saw the tooth come out and the man was extremely relieved!
We were finished by about 4.30pm. We wearily packed up the equipment for the last time and made the 2 hour drive to Tambobamba. Needless to say we ate quickly and slept well!
Day 8
We had a relaxing morning in the Hacienda garden. Enjoying the sun and taking our time getting ready for the drive back to Cusco. As always, the drive was stunning. We stopped plenty times on the way back to take photos and finish filming.
During this trip, Sean made a movie of the experience. He captured not only the work we do with the patients but what is involved in a DPP Volunteer Trip as a whole. This includes the journeys, the equipment, the relationships with Health Post workers and local people. He wanted to show the magnificent scenery of the Apurimac Andes as well as the way the team needs to work together. We have now edited this movie and it is available to watch on DVD. Sean gave a huge amount of his time and energies to make this DVD and I would sincerely like to thank him for that.
I would also like to thank Yesenia for volunteering her time and skills to treat her countrymen. It was a pleasure to work with her and I appreciated the effort she gave the project.
And finally, to work on these trips with Clark is amazing. Dental Project Peru was born from our combined visions and it is satisfying, rewarding and motivating to see our visions come to life – together.
