Dental Project Peru – Trip Report

Trip 3 – 13-20 August 2006

Gillian & Roisin

Day 1

I can hardly believe this is the 3^rd trip of the year.  It is funny.  Whilst on the trips they seem to fly by but at the same time we usually feel we have been out there for ages.  I suppose because our days are so full and experiences are always new. 

The team is made up of 5 of us as usual.  I have two volunteer dentists from the UK.  Gillian Jones is a 45 year old dentist from the town of Nairn in the North of Scotland.  Our paths began to cross when I worked in Nairn as a locum dentist in the beginning of 2005.  Gillian, her husband Malcolm and youngest son Robbie came out to Peru and enjoyed a 2 week adventure holiday before the boys left Gillian in my hands to volunteer in the Apurimac. 

Roisin Tohill is a 27 year old dentist from Northern Ireland.  She has just resigned from her job as a Senior House Officer in a hospital in Belfast to embark on a 4 month volunteering trip to South America.  Roisin has wanted to do this type of work for many years now and has finally taken the plunge with Dental Project Peru.  She has some other volunteer work lined up in the Cusco area for the weeks following her trip with DPP.

On this trip I am lucky to have with me again my friend and colleague Yesenia.  Yesenia is a 29 year old dentist from Cusco who has been working with me for 2 years now.  This will be her 3^rd DPP trip.

And our driver is Leo again.  This will be Leo’s 3^rd trip as driver.  It is great that he knows the ropes and is such a wonderful help, not only as driver, but when we arrive, set up and work at the Health Posts.

We all meet at my house at 8.30am and get the truck loaded up.  We are set to go by 10am and head off out of Cusco towards the Apurimac!

The drive is magnificent.  As we climb, the views never fail to astound me – just breathtaking.  As it is Sunday, the towns we pass through are having their market day which always provides entertainment and photo opportunities.

Because we are heading to Coyllurqui (which is a 7 hour drive from Cusco) I decide to break the journey with our packed lunches on the Apurimac side of the Apurimac gorge.  This is about half way.  From here we all enjoy the spectacular views of the 24 switchbacks that we have just encountered on the opposite side of the gorge.  The perfect picnic spot!

We carry on through the town of Cotabambas and up and over yet another pass.  Finally dropping into the valley of Coyllurqui is a pleasant change from the high altitude as we enjoy more greenery, birds and flowers.  The town of Coyllurqui lies at just 3,100m above sea level and is thus somewhat “tropical” compared to the dizzy heights we have just crossed.

We first went to the Health Post where I met some familiar faces.  I love coming back to places and meeting old friends and colleagues.  I was assured that Vilcaro and Pfaco knew of our visits for the coming 4 days. 

I meet Jose at the Alberque where we always stay.  He showed us to our rooms which are all too familiar to me.  Comfortable beds and a flushing toilet – feels almost 5 star?!?

Roisin and Gillian comment how unpleasant the toilet is.  “Oh-Oh” I think to myself.  This is probably one of the nicest and cleanest places we stay out of the entire 15 DPP villages we visit.  If they think this is bad…….  I dread to think what they will think of what is to come…… I often dread the trip when a volunteer will be “unable” to cope with our living conditions in our 8 days away from home-comforts.  I fell asleep tonight hoping that neither Gillian or Roisin will be that volunteer.  Will they cope – I hope so!

Day 2

Today has been a day I will never forget.  It challenged me in ways I never thought I would be challenged.  I felt emotions so strong and unfamiliar – they will be with me forever.  It has been a hard, difficult yet invigorating 24 hours.

Allow me to start at the beginning…..

We woke early and went to the Health Post to collect the truck.  First incident of the day – the truck had a flat tyre.  This is a first on a DPP trip.  I was very disappointed.  But Leo got straight to work and changed it for the spare. 

As we were about to leave to head to Vilcaro to work, the second incident of the day struck.  I was told by the nurse at the Health Post that Dora (the tecnica from Pfaco) had just left for Cusco for 4 days.  She would be back on Thursday.  I was gutted.  Dora is the only staff member at Pfaco and we were programmed to work there Wednesday and Thursday.  I was surprised because Dora and I have worked together for 4 years and she is always a great asset to the team.  But her not being there meant the Health Post would be locked and no patients informed of our visit.  So I quickly got on the radio and tried to contact the Health Post in Cotabambas where her bus would be passing through.  I thought if we could catch her in Cota. I could ask her to leave her keys there to be taken back to Coyllurqui so we could at least get into the Health Post in Pfaco on Wednesday.  But by the time someone answered the radio, the bus had been and gone in Cotabambas. 

Plan B:  I decided to try to track down her husband, Americo, who could at least let us into the Health Post.  He is a teacher at the school in Pfaco and I was hoping he could also co-ordinate the children in Doras absence so we could treat these patients on Wednesday leaving Dora to quickly co-ordinate the adults of the village on her return.  We drive through Pfaco on the way to Vilcaro so the plan was to stop en route.

So we left Coyllurqui for Vilcaro over an hour late.  We arrived in Pfaco shortly after and I tracked Americo down at the school.  He is a very nice man and was happy to do this favor for us especially after I did some fillings for him last year.  With things in hand at Pfaco we continued on our way to Vilcaro.

The road gets very bad on approach to the village.  The steep drops are made more dangerous and precarious by the number of landslides we need to drive over.  This road is rarely traveled by vehicles so it is not kept in any kind of “drivable” condition.  But we arrive safely.

The usual unloading and setting up started.  The first day always takes longer as I explain the “system” to Roisin and Gillian.  We have the chairs and extraction equipment, the compressor and filling equipment, the sterilizer, medications, record cards and many more things that, once in place, allow us to function like a “well oiled machine” – or at least that is the theory!

We were set up and ready to go by midday.  150 children arrived from the local school.  Leo did the Charla (education talk) for them in Quechua.  This is a fun and interactive game/lesson on what things are good and bad for teeth and how to take care of our teeth.  The kids loved it! 

I then screened all the children.  Generally the amount of decay and infection was huge!  Oral hygiene and awareness are practically non-existent and that is so disappointing.  But we all got to work and treated the pain and infection of the children. 

We stopped for lunch about 1.30pm and quickly ate some sandwiches before getting back to the children.  At about 3.30pm I was called out of the surgery by Leo…..

He told me someone was asking to use the truck.  I went outside to be confronted by a man in military uniform (complete with gun).  He told me there had been a terrible accident and three men were badly hurt.  One man was in critical condition and they needed us to collect them in the truck and bring him back to the Health Post.

Leo and I quickly grabbed some surgical gloves, jumped into the truck with the solider and another man who looked like he was in shock.  His eyes were very wide, he was staring and breathing very fast.  As Leo drove at high speed in the direction the solider indicated, I asked the other man what had happened.  He struggled to speak at first but eventually told me that a group of men (including the military) had been working on the other side of the valley.  They were building the road along the mountainside.  As they were blasting their way through the rock, the ground beneath 3 of the men collapsed.  These three men fell, tumbling out of control to the valley floor – to the river.  Their fall had been over 800 metres!  The sides of the valley were sheer and as the men fell rock and debris fell on top of them. 

Their co-workers watched them fall.  There was nothing they could do.  But the Captain in charge of the men went down the cliff side after them to their aid.  Following his lead, other men went slowly and carefully down too.  At the bottom of the valley the three men lay injured and in pain.  Two of them were conscious but the other lay unmoving and unconscious.  He was still breathing.

This was when the young man in the truck and the soldier came to get our help.  The soldier told us to stop.  As we jumped out, we saw and heard the group of men carrying a man on an improvised stretcher up out of our side of the valley.  As I helped them get him into the back of the truck I saw before me a sight I could have never imagined.  There was really no time to take it all in as the Captain pulled me aside and told me quickly how far he had fallen, that he had been breathing when they found him and that he needed for ME to care for him.

Leo and I got in the truck and drove back to the Health Post with some other men supporting the patient in the back of the truck.  When we arrived at the Health Post, a crowd had gathered to see what was happening.  As there was no other way to get the man over the muddy and stony terrain to the clinic, we put him on a birthing table and carried him up the slope to the clinic.  Or at least it was a building that had a cement floor and walls and was the cleanest place available to us.

The tecnica, Tanya (one of 2 staff members with 3 years medical training) came running to me asking what had happened.  I quickly filled her in.  The men who helped us were crowding around him and asking if he would be ok.  They were all very upset and concerned.  I asked them to wait outside.

A 23 year old man named Augustine lay before me.  Although recognizable as a man, his body was so badly bleeding and torn and smashed up it was hard to imagine what he had looked like before he fell.  His eyes were closed.  The eyelids were very puffy and purple and there was blood oozing from behind them.  His nose was shifted to one side of his face and swollen.  With his mouth slightly open I could see that all of his front teeth had been smashed out and his mouth was full of coagulating blood. 

A pool of blood formed from under his head on the birthing table.  As I placed my hand gently under his head I could feel and see fresh blood pouring from his scalp.  There was also a large gash in his temple that was adding to the blood loss.

The worst visible injury was to his left arm and hand.  His left wrist was clearly broken as it lay at the most peculiar and unnatural angle.  There was an enormous amount of blood pouring from his hand and when I turned his hand over I could see that his thumb seemed barely attached to the rest of his hand.  The huge gash in the palm of his hand extended from between his thumb and index finger to where his hand met his wrist.  I could see bone through the blood and flesh.

His body was covered from head to toe with dust and dirt.  Blood and dust mixed together on his skin leaving him covered in caked dark redness.  We cut his shirt off to try to get rid of some of the dirt.  But it was everywhere. 

All the while, Augustine breathed.  I will never forget that sound.  Every breath he took was audible to me for the two hours that followed.  After every breath, I waited to hear the next – hoping the next would come.  His breathing was wet.  It sounded as though he was breathing under water.  It sounded like his lungs were filling up – the reality was they probably were, with blood. 

Tanya and I looked at each other.  Neither of us were doctors with any training or experience with these kind of injuries.  What were we to do?  Simultaneously we both started to work together.  We spoke out loud as we tried to prioritise what actions to take. 

First – stop the bleeding.  We quickly realized the patient’s situation was made 1000 times worse by our situation.  The Health Post was very poorly stocked.  We had practically nothing to work with.  I shouted for Yesenia to bring me sutures from our dental kit.  Meanwhile I grabbed as much gauze as I could find and tried to stop the bleeding from Augustine’s hand.  It was then I realized Augustine could feel his pain.  As I moved his arm to close the wound, he wrenched as the pain shot through him.  My God – he could feel everything that had happened to him and everything we were doing to him.  I shouted for painkillers.

I managed to curb the bleeding from his hand by bandaging the wound closed.  But it still bled.  The gashes in his head were harder to stop.  Yesenia came with the sutures and we sutured the wounds closed.  The bleeding stopped but not without Augustine feeling every stitch.

Meanwhile Tanya was trying to put in an IV in order to replace the fluid Augustine had lost.  She could not get a vein.  But she persisted and then I helped and we finally got it in.  But the only fluid the Health Post had was Saline.  But that was all we could do.

I needed to give him something for the pain.  Someone brought Diclofinaco – this was the one and only 5ml ampule in the entire Health Post.  We gave it to him IM. 

I had asked someone to get oxygen.  They came back and told me the cylinder was empty!  But I remembered I carry a small cylinder with us on the trips.  Someone ran to get it for me.  So he was given oxygen.

Just then, the Captain came in.  He too was covered with dust and dirt and was bleeding from his head.  He said he was ok.  He asked me how Augustine was.  What could I say?  I told him we had done our best to stop the bleeding, that we had an IV in, that he received painkillers and oxygen.  We were monitoring his Blood Pressure - it was low but not critical.  But when I listened to his chest, his lungs sounded very wet.  Apart from that, I could not tell him any more.  I had no way of knowing.  But my fear was for what was going on inside of Augustine.  Inside where I could not see or could not touch.  I could only imagine the extent of internal damage and bleeding.  We both stood for a second and looked at Augustine – things were bad.  We needed to get him to a proper hospital immediately.

Someone in the Health Post had been radioing Coyllurqui to tell them to send the ambulance and doctor.  But there was no answer.  So the Captain said he would call the village phone in Coyllurqui.  (To this day, I don’t know how he did that but he later came to tell me he had gotten a message to a lady answering a phone in Coyllurqui.  She said she would get word to the Health Post so they should come to help us as soon as they heard).  Meanwhile, Leo had gone back to collect the other two men in the truck.  They had just arrived.  The soldiers came running to me saying “Doctora Doctora – you have to take care of the other two men”.  I wanted to say “I am not a Doctor” but instead I went to the men. 

They were both lying on the ground where the men had placed them on mattresses.  They were both conscious and able to speak to me.  One man was in severe pain from his back.  He was also bleeding from his scalp. (We got him stitched up).  The other man could speak to me and said he thought he was ok apart from a lot of cuts and scrapes and a badly broken nose.  What was strange was he had a ring of thick plastic around his head tied under his chin with a piece of string.  Later I was told it was the inside of his workmans helmet.  He had actually tied his helmet on (unlike the other men).  Unfortunately the actual protective helmet had been ripped off during the fall but with his more minor injuries it appeared that the helmet had remained in place long enough to give him a crucial amount of protection – had even saved his life.

The Captain came to me again and we both agreed we were so concerned about Augustine, we would drive him to Coyllurqui ourselves or at least until we met the Ambulance.  So with the help of the soldiers we carried him to the truck and placed him on a mattress in the back of the truck.  The Captain grabbed my arm and said “please go with us”.  So I jumped in the back with him and Tanya.  With Leo driving, we took off for Coyllurqui. 

That drive was the quickest hour passing yet one of the scariest of my life.  I should have been scared for myself in the back of the truck with the tail down (to make room for Augustine’s long body) as we screamed around bends and corners on bumpy, stony, slidey dirt track with sheer drops just inches away.  But that was not my fear.  My fear was that Augustine would not take another breath. 

The Captain held the IV fluid from Augustine’s arm.  Tanya tried to take a Blood Pressure and I held the oxygen cylinder and tried to keep the mask on Augustine’s face.  I kneeled over him, straddling his body in an attempt to balance myself, keep him from moving and hold the mask in place.  From that position I could lean forward to hear his breathing.  It was getting much more laboured and sounded wetter and wetter. 

About 30 minutes into the drive, blood started coming from Augustine’s mouth and nose.  It was filling the oxygen mask.  I felt my heart stop.  What could I do?  What was happening inside this poor man’s body.  What could I do?

Then the oxygen ran out.  It was only a small cylinder and we had used it up. 

The rest of the drive I just remember looking at him and asking for another breath after the last one.  The blood was oozing from his hand again and pooling around my knee.  We tried to cover him with blankets to stop him from getting too cold.  But there was nothing more we could do.

With no oxygen left, I did not need to hold the cylinder and mask.  My hands were free.  So I held Augustine.  And I willed him to hold on.  I willed him to keep breathing.  I asked him not to die here in the back of this truck in my arms.  But to hold on until someone else could help him – someone who knew what they were doing and had equipment and materials to save him.

I looked up from him and saw his 19 year old wife looking at me from the inside of the truck.  She lived in Vilcaro with Augustine and their baby son.  She was distraught and in tears.  I could hardly look at her – I could do no more to save her husband.

Just before we arrived in Coyllurqui, we met the ambulance coming the other way.  I motioned for the doctor to come quickly and explained the situation.  She was a young lady doctor from Lima who was just out of medical school.  She had never seen anything like this either.  There was nothing she could do while we stood there in the middle of the road.  So we transferred Augustine into the Ambulance (which was actually just a truck like ours painted white with a red cross on it and the bed of the truck covered over) and they took off with him, his wife and the Captain.

We later heard they had taken him straight to Cusco as we had hoped would happen.  Although this was a 7 hour drive on dirt road which would itself put Augustine in further danger – there was no alternative.  He needed to be treated in a hospital by experienced doctors and surgeons with appropriate equipment.

Leo, Tanya and I drove back to Vilcaro.

While we were away, Lucy, the other Tecnica and Yesenia had taken care of the other two men.  They were stable.  They were in a lot of pain (as there was no more pain medication) but were grateful to be alive.  The worse of the two had three severe head wounds, severe back pain and struggled to breath when moved.  We discussed what to do and all agreed that they too should go to Coyllurqui for the doctor to check and then probably to Cusco.  There was no way for us to know what kind of internal injuries they had and any necessary treatment was impossible here.  So we loaded them both into the truck.  Leo drove them to Coyllurqui.  From there, another “ambulance” was sent from Cotabambas to take them to Cusco.

When they were gone, I realized I had completely abandoned poor Roisin and Gillian.  They had carried on treating the waiting dental patients and done a wonderful job.  I was so grateful for them being there.

Once the adrenalin stopped pumping and there was nothing more to do, I sat down.  I was covered in Augustine’s blood.  It was on my arms, my neck, my tunic and trousers.  I could smell it on me.  As I sat there, what had happened began to sink in - and I cried.

Day 3

We all woke this morning feeling relieved the night was over.  None of us slept well.  We put it down to it being unusually hot and there being a lot of bugs and moths flying around.  But I think it was impossible to sleep well where we found ourselves sleeping.  There was no other option but to clean the space where we had treated the three men, and lay out blankets and our sleeping mats and sleep there.  Personally I think there was no way to rest easily in the same place that such pain and trauma had taken place just hours before. 

But we all got up and pulled together as a team and decided we would face the day strong and ready to help people.  And that is what we did. 

We saw all the secondary school children in the morning after doing the Charla and screening.  And it was great to be able to do some fillings too and save some teeth!

The kindergarten children came and were absolutely gorgeous as always.  Unfortunately two of them had bad abscesses on tiny milk teeth.  They were necessary for extraction and Yesenia did a great job of treating both the wee 4 year olds.

Then another 150 children arrived from a distant community.  They had walked about 2 hours.  The screening showed much better oral health with less rampant caries than the children here in Vilcaro.  There were still over 40 children requiring extractions but it does reinforce my theory that the further away communities suffer less as they have less access to sweets and fizzy drinks.

In the afternoon, the mother of my God-daughter – Jacqueline came for treatment.  As always she brought us food.  She always shows her gratitude for the help I gave when Jacqueline was born.  Roisin treated her.  Over the years she has had the odd painful tooth out.  But today she asked that we take out all the remaining roots and teeth.  This totaled 20 teeth!  Most of them were infected little stumps and were of no use to her.  I agreed the best treatment was clearance but took a lot of time to explain how important it is to keep things clean afterwards to avoid infection.  With all this said, she insisted she wanted the treatment.  So Roisin embarked upon the epic journey. 20 extractions and numerous sutures later a tired Roisin and an even more exhausted patient were pleased for it all to be over.

Little Jacqueline is a beautiful healthy wee girl.  It is amazing to see her so big – 4 years old!  I can hardly believe it.

Then Nely arrived.  This is the mother of Joseph who is the baby that myself and Leslie (a past volunteer) “helped” deliver.   He is so big and so chubby and smiley.  Again, a wonder to see him growing up.  Nely is a very sweet lady and I extracted five of her teeth for which she was very grateful.

As we were working away, Leo came and asked for word with me.  As we stepped into the other room, I knew what he was going to say.  He had just had word on the radio from Cusco that Augustine had died.  He had arrived in Cusco the night before but had massive internal injuries and cerebral hemorrhaging.  He had held on for 24 hours since the fall, but had passed away.

My heart sank.  I felt numb.  He never stood a chance.

Day 4

We woke up back in the Alberque in Coyllurqui after driving back last night.  We had battled our way to our room through the throngs of people queuing up to receive their DNIs (Documento Nacional de Identidad).  Everyone in Peru is supposed to have a National Identity Card which allows them to vote but most importantly allows them to exist in the records of the country.  Without this identity card and the records attached to it, the country does not know you exist or recognize you.  This is a once a year chance for the people of the Coyllurqui area to receive this document.  But it is not given to them.  They have to pay 30 soles for it!  That is the equivalent of almost $10 or 7 pounds.  Many of our patients do not have 1 sole.  How are they supposed to get 30 soles together in order to be counted as a Peruvian?  A very strange and complicated system. 

But we were awake now and grateful for a good nights sleep.  We were ready for our next village – Pfaco.  Except we were not 100% sure how it was going to pan out, considering the lady staffing the Health Post was in Cusco!  We shall see……

We arrived in Pfaco to find the Health Post open for us but no-one around.  So we just made ourselves at home and installed DPP.  This Health Post is a pleasure to work in as it is so clean and organized.  Or at least it is until we arrive!

We took the opportunity to take in the beautiful surroundings and catch our breaths before the entire school arrived escorted by Americo and the director of the school.  So we got to work!

Leo did a great Charla.  The kids loved it and so did Leo!  Then I did the screening and we started treatments.

Unfortunately, Pfaco is notorious for “criers”.  Generally the children in the Apurimac are very brave and do not cry too much.  But during my time in Pfaco over the years, I have come to know it will not all be smiles and laughter here!  Although we always do everything we can to comfort the children and insure they are not feeling any pain, the fear factor is infectious.  When one child cries, they all do.  This makes our work 100 times harder and more stressful.  There is nothing more exhausting and heart wrenching than the child you are trying to help, screaming because they are frightened of you.  That is when the communication and language barrier really is very frustrating for the volunteers who are unable to reassure their patient.  I feel so bad for volunteers when this happens.  But always reassure them they are still doing a wonderful service for these children and it is not their fault the children are upset.

Roisin and Gillian did really well.  We were all happy to take a well deserved lunch break and get back to work feeling rejuvenated.  The children in the afternoon were older so there was less crying.  We also did some really nice fillings.

The afternoon was quieter and more relaxed.  We cleaned up and headed back to Coyllurqui to sleep leaving all the equipment in the Health Post for the next days work.  On the way back (without any equipment) we were able to pick up some passengers to save them the walk home.  Roisin fancied traveling in the back too so hopped in and enjoyed the open-air ride back.

We played cards and felt relaxed that night.  We all slept well again.

Day 5

We had been unable to find Dora the night before.  I was told she would be on the bus from Cusco.  When I could not find her, I was disappointed as I thought she would not be there today and thus patients would not be told of our visit.  So we took our time in the morning and arrived back in Pfaco about 9.30am.  I was surprised when we arrived……

Dora was there.  (She never fails).  She had gotten to work early and got the word out to people that this was our last day.  There were already about 15 people waiting when we arrived.  We felt a bit guilty and got straight to work!  We worked straight through to 6.30pm!

It was mainly adults we were seeing with quite a lot of fillings.  But there was one tiny little girl who restored our faith in tranquil children.  Gillian treated her.  She was a beautiful 5 year old girl who came of her own accord for an extraction.  We all thought she would be a screamer but were all amazed at how she sat with mouth wide open staring at Gillian the entire time with the most beautiful big brown eyes.  She received her anesthetic and extraction without a peep.  Well done Gillian!

A gentleman came in who I recognized straight away.  This is the third time I have seen him.  He has a huge gingival growth in his lower left quadrant.  I was scared in the past that it could be a malignant tumor and had told him to go to Cusco for tests.  (He never did).  But now I am less concerned as it has changed very little since last year.  We all agreed, as we did last year, that it would be unwise to try to cut the growth away without finding out what it was caused by.  So I asked him what he would like us to do.  He said he wanted all the associated teeth extracted.  These teeth were all non-functioning as the growth had distorted their position in the mouth.  So I agreed to take them all out.  That was 7 teeth.  He clotted well and was very grateful.  We will see next year if this has helped his situation at all – I hope so!

There was a nice filling case where we saved the upper anterior teeth of a teenage girl.  All 4 teeth had caries and we got to them just in time to avoid loss of the teeth.  Very satisfying.

As Yesenia treated the last patient for anterior fillings, the rest of us packed up.  It was already dark and we were all tired.  By 6pm the truck was ready to go.  We were about to drive off when a big lorry pulled up to the Health Post.  It was the vehicle carrying all the soldiers from Vilcaro (who had been working on the road when the accident happened).  The boss came to me and asked if I could treat one of the soldiers.  I explained that all the equipment was packed away and difficult to get to and we were all exhausted.  He pleaded with me and explained the young soldier had been up all night wailing and crying in pain.  What could I do….???

I remembered Dora had a small box of extraction forceps.  I asked her to bring them and I set up a chair with a blanket against the wall – just like I did before DPP had any equipment.  The young man came in and pointed to his lower right molars.  Both were completely shot.  I said I would take them both out.  It was not easy.  As I stood there, I told myself to take my time as they were really tough.  I was really hoping not to break them and have to spend another hour digging them out with hardly any instruments.  The pressure was on with all my team, Dora and Americo, and a handful of soldiers watching.  But both teeth came and both the patient and I sighed a big sigh of relief.

From Pfaco we drove 2 hours to Cotabambas where we were delighted to stay at the Convent with my friends the nuns.  They gave us a lovely room which even threatened to have some hot water in the shower.  We slept well.

Day 6

We were up at 6am this morning and on the road to Occaccahua.  The drive is beautiful as we climb to over 4,000 metres.  We leave the main road and bumble over rough terrain often making our own way with no obvious path to follow.  The truck does great.  Finally, at about 9am, Occaccahua comes into sight.  It is situated at over 4,400 metres in a barren and desolate landscape.

But the children warm our hearts!  They come running when they see the truck.  When we arrive we are met by the sight of a beautiful new Health Post.  It is shiny and new with lovely tiles and paintwork.  We see two porcelain toilets and get very excited but are disappointed to find out there is still no running water or electricity!  Looks can be deceiving.

We unload the truck but before setting up we all reach for our bags to put on at least one extra layer of clothing.  It was freezing!  We are set up and ready to go by 10.30am.  On arrival the very helpful tecnico, Milkha, had done a tanoy announcement of our arrival and that there would be free dental treatment for the next 2 days.  So that was the entire village told!

Leo and Milkha had gone to the school while we were setting up to inform the director we were ready to treat the children.  So they all arrived – or at least about 50 of them. 

We have two large banners that we put up at every Health Post when we arrive so people know who we are and what we are doing.  They have the logo on them but also a photograph of two little boys sitting with the tooth model and brush.  These two little boys are Paulino and Sergio – they are from Occaccahua.  So the best thing was to see the two wee boys come round the corner to the Health Post and see themselves up on these huge banners!  Their faces were a picture.  I have been waiting so long to see them see themselves.  All the kids were pointing and laughing and so excited.  Paulino and Sergio were so proud!  So we took some more photos with them – two years on.  It was great!

Then Leo did the Charla and I did the screening.  Paulino was the first in the queue.  He is a little orphan who lives with his aunt.  He is very skinny but has the most beautiful smile.  When we were here last year, my friend Marly and I gave him new trousers and a jumper to wear.  He was wearing them now.  To have a recurring connection with a community and certain children in particular is very special.

We worked through the afternoon seeing all the children.  Their teeth are not as bad as other communities because they are so remote here.  But still plenty of pain and infection to fill our day. 

We had one young boy who had 2 permanent molars extracted.  He bled a lot.  We controlled it and told him he could not go running about.  And hour later he was back bleeding again after playing football.  We controlled it again but he did not seem to understand the link between running and bleeding.  Eventually (after returning again with a mouth full of blood) he understood!

As the day went on it got colder and colder.  Neither Gillian or Roisin complained about the fact that we were to spend the night here – but I could tell the prospect of this was not being relished.  We were not mobbed with patients and so I put it to the team that instead of staying here we could drive 1 and a half hours to Tambobamba and stay in a hacienda there.  Also, there was the chance of eating roast chicken there too.  Everyone’s faces lit up.  It was decided.  We would go to Tambobamba.

The drive was beautiful with a wonderful sunset.  I got a very familiar feeling during the drive.  It is a happy, content feeling.  I feel aware of the sky, mountains, animals, people.  I feel connected to the environment here.  I feel alive.  But it is so hard.  I find myself stressed and exasperated one hour and then overjoyed and happy the next.  There is no average day with this work.  Many emotions come over me in such a short time.

We were all happy campers in Tambobambo.  After eating wonderful chicken, we went to bed.  Yesenia and I slept in a room with a window that had no glass.  Two donkeys stood outside and loudly “naahhed” us to sleep.

Day 7

Woke up in Tambobamba and went shopping!  There is a tiny wee boy in Occaccahua who has to hold his wee trousers up all the time otherwise they fall down.  In fact, they are not even trousers but rather pyjamas.  So I stopped off and bought him a nice warm pair of fleecy trousers – with elastic!

Back in Occaccahua we have a quiet day.  The patients trickle in.  The children are so beautiful here – we get the opportunity to play with them and take lots of photos.  They love seeing the little videos we make of them dancing with the digital cameras!

Roisin, Gillian and I took a walk in the afternoon to try to find little pyjama boy.  While walking through the village between the adobe houses we were chatting and relaxed.  Then a dog came from nowhere, barking with its teeth bared.  It was so frightening.  He went for Gillian but she was amazingly brave and stared him down.  He backed off.  I was so impressed!  But we promptly turned around and went back to the Health Post.

A 69 year old man came for his upper left second molar to be extracted.  Roisin was treating him.  Whilst in the chair, he got quite upset and started to cry.  He was telling us his story in Quechua.  I could understand enough to know he was sad because he had had a wife who was a widow with 3 children.  He had raised the children as his own.  But last year, the lady left to go to Tacna in the south of Peru and took the children with her.  He was now alone and heartbroken.  It was very sad.  We tried to comfort him and this demonstrated how sometimes there is no barrier with language.  A look and a touch on the shoulder can mean a lot.  Later he returned with his hat full of potatoes for us to say Thank You.  A very sweet man.  He did plant a kiss on Roisin which was a little more gratitude than she expected!

It is adobe brick making season.  So all the men that come for treatment come straight from the pits of mud.  They come with their bare feet and mud up to their knees.  It is a community activity and everyone takes part. 

We get packed up early but have to wait a while as Leo is fixing one of the “muelles” on the truck.  (not sure what that is in English but it is part of the suspension).  So we watch and wait in the sun.  He fixes it and we set off back to our comfortable convent.

I am in bed and asleep by 9.30pm.  I can hear Leo and Roisin still playing cards as I drift off into a very sound sleep!

Day 8

We get up early even though we had only to drive 5 hours back to Cusco.  Everyone had agreed to help me with the massive clean up today when we get back to Cusco because I have to fly to Lima at 7am tomorrow.  So I am very grateful as everyone rolls out of bed before 7am.

The drive back is wonderful as always and we all enjoy our own thoughts and feelings of accomplishment, excitement and the knowledge that we have been to a place and visited people in such a unique setting and had this unique experience shared by few.  It is a special part of the world housing special people.  I am proud to be a part of it and to have had the opportunity to share it with Roisin and Gillian.