Wednesday, February 29, 2012

Lima, Peru

By:  Jim Ross, MD

Secret of the Andes, by Ann Nolan Clark, was a book that I stumbled upon as a child. It is a story of cultural mystery and personal identity. The main character is a modern-day Native American boy who along with his guardian tend a herd of prized llamas in an isolated valley in the Andes Mountains in Peru. The boy is unaware that he is a direct descendant of the ruler of the ancient Incas. Throughout the book, he is instructed by his guardian in the religion and history of his ancient people, and goes in search of his true identity. Growing up in Minnesota I was fascinated to learn of a different type of culture such as was presented in this book. The descriptions of the culture, nature, and history were fascinating to me. I had visited my girlfriend’s family in Peru prior to this opportunity, but had little interaction with the health care system nor understood the difficulties of treating patients in this poverty–stricken environment. I have always had an interest in over-seas volunteer work, and have always wanted to create contacts in order to volunteer on an annual basis. This was the perfect opportunity for me to visit one of the hospitals in Peru, establish contacts so that I can continue to assist the health care and also provide education to the Orthopaedic department.

Dr. Gaston Barnechea is an Orthopaedic Surgeon who is also the contact for the Nacional Guillermo Almenara Irigoyen Hospital (Almenara Hospital). He assists in coordinating volunteers as well as Project Walk, which is an established program that provides joint arthroplasties for those in need. The Almenara Hospital is part of the El Salud Health System, which opened its doors in 1941. It is located in La Victoria, which is one of the 43 different districts that are a part of the city of Lima contributing to a population of over 7 million people. It was originally envisioned to become the center of Lima, as a commercial and industrial empire, with the largest textile industry in Lima in addition to several stores, shopping centers, and workshops. However this area has become partially overrun by the highest crime rates in Lima in addition to a “recycling” center in which garbage is essential dumped on the various streets and is rummaged by the people in the area. The hospital is also near the medical school, the University of San Marcos, as well as the training facility and stadium for the Club Alianza Lima, which is the Peruvian first division soccer club that is the one of the most famous and well-supported clubs in the country and the oldest teams in the Peru.

The hospital currently has approximately 1,000 inpatient beds however has many overflow areas. There is also a very busy emergency room as well as an ambulatory day surgery center with 14 operating rooms. The inpatient wards are organized around a nursing station, and each ward is dedicated to a specific specialty. Orthopedics/Traumatology has one ward which houses nearly 100 patients. However, given that the Orthopaedics ward is always at maximum capacity, patients are also scattered amongst the other wards. The Orthopaedic/Traumatology service is divided into 2 separate teams. The team that I joined was one that dealt mainly with trauma and joint reconstructions. The other consists of surgeons that specialize in spine and hand surgery. Within each team, there are approximately six surgeons who are assigned different shifts. The operative days are divided into a morning shift, which runs from about 8:00 am to 2:00 pm and an afternoon shift, which runs from 2:00 pm to 8:00 pm. Each team is given one room, and within that room 2 of the staff members operate together. Each team is also assigned 2 residents, who in addition to taking care of the inpatients at Almenara Hospital spend time in other hospitals in the area. They usually take turns scrubbing for the cases. The residency program is 3 years in duration and is spread out amongst various hospitals throughout Lima. In total, there are on average 30 residents in Lima, 4 of whom are at Almenara Hospital at a given time. There are no formal lectures or education and thus the residents and staff were always eager to learn.

After my first trip to the hospital, I instantly realized why the hospital sees the vast array of trauma. There are essentially no stop signs or traffic lights at the intersections, and each car is fighting for its space in the street. Amongst the many cars, there are also many people riding scooters, motorcycles, and “moto-taxis” which is essentially a dirt bike with a carriage attached to the back. All of these vehicles are in addition to the many people who are walking across the streets or standing in the center of intersections selling various items and food. Taxis are very inexpensive as a trip to return to my hotel which was approximately a 20-minute ride was usually 15 nuevo sol (~$6) and would fluctuate depending on my bargaining skills.

The typical week started on Monday with an indications conference. The residents would present all of the current inpatients and new patients that were admitted over the weekend and treatment would be discussed amongst the staff. Given that a majority of the implants are not within the hospital, treatment would be decided and the implant companies would be contacted. One of the difficulties, however, is that implants such as femoral nails or proximal tibial locking plates usually takes well over a week to be delivered to the hospital. A vast majority of the fractures are treated at 3 to 4 weeks in addition to many nonunions and pseudoarthroses that are years old. It was very humbling to realize how lucky we are to have all the various instruments at our immediate dispense.

My Monday afternoons, in addition to the remaining week days would all consist scrubbing in all the cases. There were a vast array of fractures including multiple tibial plateau, ankle, hip, long bone, and pelvic fractures. There was a gunshot to the proximal tibia, which the staff found very interesting as they see about 3 to 5 fractures sustained from gunshots per year. They were astonished when I mentioned that our trauma service sees that amount usually within 2 weeks. The highlight of my operative experience was teaching the staff various techniques that they had not used and teaching the residents simple techniques such as interfragmentary lag screws and reduction techniques. I was also fortunate to show the staff percutaneous sacroiliac screw fixation. This had to be planned well in advance, as there is only 1 fluoroscopy machine for the entire operating rooms, so more than 90 percent of the cases were done without fluoroscopy. Intra-operative decision-making is also very different in that one has to be quite creative given the limited availability of supplies.

Given that many patients have delayed operative fixation of their fractures, it is not uncommon for external fixators to be placed in the emergency room. There is a procedure room in the ER where small cases are performed, including ex-fix applications. Some of the patients that have ex-fix’s placed end up having this as their definitive treatment if their wait for surgery is long enough. Despite being a hospital with limited resources, it is still difficult for a patient to be admitted. The patients that are allowed admission are those that have priviledges similar to the U.S. Medicare/Medicaid system. Spanish serves as the primary language amongst the patients and the staff. The staff knows little, if any English, which put my Spanish to the test and made some discussions difficult especially since medical language is different in itself.

The weather in January, which is considered the beginning of summer, was consistently in the 80’s with lots of sun, few clouds, and only occasional rain at night. The country prides itself on Peruvian cuisine, which I agree is the best food I have ever eaten in my life. Ceviche is a staple that is prepared with uncooked fish or other marine life that is marinated in fresh lime juice and aji amarillo (a salsa of spicy yellow pepper). My other favorites included anticuchos (grilled beef heart), lomo saltado, conchitas a la parmesana, causa, and of course Cusquena and Pilsen (Peruian beers). The also tasted fruits that I have never seen or heard of before, and all the fruits that are found in the United States were much better there. I was also very fortunate to have an additional week to travel with my girlfriend and her family, experiencing the culture and various scenic areas that the country offers.

Overall, the patients have immense gratitude to the physicians, quite frankly more than I have ever witnessed before. They are constantly thanking the physicians and family members will seek out the physicians to thank them for their caring for their family members. It is quite remarkable and humbling, and I cannot wait to visit again. Viva Peru!!