Walking back in time

After a long overnight flight, I returned home this afternoon.  I will certainly miss all of the warm, friendly people, excellent food and the many friends I have made while in Peru.  Yesterday, Ana walked to my hotel at 10 a.m.  We walked all over Lima, including a very neat town; Barranca.  I can barely write the word without laughing.  She told me I had to be able to say it before crossing the town line.  I practiced a few times but realized, it was inevitable: no matter how hard I tried to get it, I am American and the tongue roll does not come naturally.  I then challenged her to a few words like uncle (came out as ankle!).  So we walked all over Barranca saying Barranca and uncle.  Neither one of us had an impressive debut.  Barranca was a very cool town.  It was like stepping back in time, all of the buildings were very old with incredible architecture.  I have always enjoyed architecture but never imagined I could thoroughly enjoy an entire day of looking at the intricate designs.  We stumbled upon a Peruvian Hairless Dog which originated in pre-inca cultures.  This wasn't necessarily a dog you would walk up to and say 'oh, he's adorable, can I pet him?' but cute in a different sort of way (I am not sure how to explain it haha).  He had some sort of skin disease or acne, a mohawk, hairless body and a little hair on his tail.  I think it might have been the mohawk that made him cute.

we stopped in Barranca for ceviche (raw fish).  Much to my surprise, I enjoyed it.  The fish is marinated in a lot of lime juice which changes it's texture.  We walked to Miraflores and shopped at the Inka Market until I had to go to the airport.  Inka Market is a street full of paintings, ceramics, alpaca and other art.  The colors in all of the Peruvian crafts are so bright and colorful; they are wonderful!

Barranca-the art district, home of many composers and artists

Vibrant colors in Barranca

Mom and son selling gum on the stairs

A surfer's paradise!

A neat home

Railroad crossing

A church under construction

Stone beaches in Miraflores

Home of Sofia Molanovich who won the countries first world surfing championship in 2004

Paraglider in Miraflores 

An exciting day in the post-op ward!

Yesterday morning I did rounds in the post-op ward.  This was very different than what I am used to.  Not that a hospital is an exciting place to be but this had a very different feel.  Very gloomy and sad.  The first patient we saw was a woman 8 days post-op total shoulder replacement.  It was nice to finally see a patient early on that did not have a contracture.  When I arrived, the woman was holding a cross, crying and rocking back and forth in her chair.  She told me she just wanted to go home.  She also asked me if she would ever be able to cook again.  She said the nurse told her she would not be able to cook or garden again because her shoulder might dislocate.  She was left there crying.  I tried to comfort her and explained that she would use her arm again and explained the course of rehab to her and her therapist.  I told her I would be at her house next month for dinner so she needed to get better haha.  She laughed and said only if I brought lobster from Maine!

The next trauma case we saw was a young man that was in a car accident and glass severed his radial, median and ulnar nerves and radial and ulnar arteries.  He had skin grafts from his stomach, nerve transplants from his femoral and peroneal nerves, and artery bypass surgery.  He had this done 3 months ago and it was his first day of therapy.  He had keloid scars about an inch in height and he did not have any range of motion or strength in his wrist.  We were able to make great gains in his range of motion using a variety of different techniques including a homeade skin suction device (a syringe with a rubber plug that was shaved). This seemed to do the trick and drastically mobilized his skin!  Not having all of my supplies has forced me to get creative, which is not necessarily a bad thing! I mentioned to the therapists that since he does not have sensation on a majority of his arm, he should not be given modalities which could burn him.  They said it was too late, they had put him in the whirlpool and he suffered 2nd degree burns over his already traumatized arm.  There were still some visible open wounds from this, but we were able to work around them.  I was happy to hear one of the therapists say 'this is why we need to document.'

Supination before treatment

Supination after treatment

The suction device

I was amazed to see how the patients get in and out of bed.  They climb a set of four stairs to get into bed and use a trapeze to hoist themselves up.  It is a big process for the nurses to get patients in and out of bed so I can see why many of the patients are in bed for such long periods of time.

Sorry to bore you, but I have rarely seen cases of such severe trauma so I am hoping you will also find it interesting! The next patient had steel fall on his legs while at work and broke his right tibia and left femur.  He has been in bed for 3 weeks for his left femur and just had his right tibia operated on 3 days ago.  This means he is looking at another 3-4 weeks in bed.  He has many pressure sores, the biggest on his heel.  When I arrived he had a massive headache.  The nurse showed me his list of meds- he was taking very high doses of 10 pain meds simultaneously and said he has had a horrific headache for 3 weeks.  This therapist did not seem very open to suggestions as far as taking pressure off of his bed sores and starting to work on strength and range of motion where concerned.  I think if anything, the patient understood the importance of these issues and will hopefully take matters into his own hands.

The patient's right tibia post ORIF 

The patient's left femur post ORIF

The femur fracture before surgery

The evening concluded with a photography tour at the National Museum (from the 11 years of terrorist attacks).  I cannot even begin to imagine what life must have been like for the Peruvian citizens during that time.  Ana took me to a restaurant on Larcomar, overlooking the ocean which was wonderful.  

Yesterday was my last day at Almenara and the students chipped in a bought me a bracelet.  It is beautiful and the stones on it  have great meaning.  I was invited by one of the orthopedic surgeons to speak at the Peruvian National Arthroscopy meeting next June which is exciting! Off for one more adventure today before returning home on a red eye tonight!

Ana and I

Part of the crew at Almenara 

Sheri, a volunteer in internal medicine-at the Inca Market-she is great!

A good start to documentation!

Some of the therapists and University students

Transportation in Miraflores

An olive tree near Ana's house

Exercise equipment on the side of the road! 

A success story

Today I had a patient that fell 5 floors, 4 months ago.  He came into the clinic today and was using two crutches and not putting any weight on his right leg.  He said his foot was so sensitive, he was unable to put his foot on the ground.  He works in a factory and his wife said 'he got so stressed out about not being able to work, he had a heart attack.'  Shortly after his fall, he was in the hospital for his heart.  Today was his first day of therapy and he has not walked for four months.  I evaluated him, which was a challenge because I could barely touch him because of the sensitivity.  His evaluation said 'ankle pain, electrical stimulation for 12 visits.' I asked the patient if he had any sensitivity to hot or cold and he said he has not been able to leave his house often because his ankle is so sensitive to the cold (although still warm, this is the Peruvian winter).  He had some obvious discoloration and extreme sensitivity to very light touch.  I explained to the group that he appeared to have complex regional pain syndrome.  A term relatively unfamiliar to the healthcare workers in the hospital.  They were very excited to learn about it and the treatment options.  We started some desensitization exercises and did a contrast bath.  He stood up, was able to tolerate the pressure and asked if he could donate his crutches to the clinic! The therapists were amazed that the little treatment we did was so helpful.  Unfortunately, the patient then had to go sit in the corner and receive his electrical stimulation after we treated him.  Since the therapists are working for the physiatrists and have no autonomy, they are forced to do the modality requested.  The physiatrists will ask the patients if they received the modalities and if not, the therapists will be punnished.  I asked Dr. Barneccea, the orthopedic surgeon that picks me up each morning, why the therapists do not have any autonomy.  He said it is because the therapists do not have any documentation, and since the physiatrists are their dictators, it is their license that is on the line if someone were to sue them.  So, they prescribe only modalities to protect themselves.

One of my jobs while in Peru is to help to institute a documentation system that can accommodate the therapist's busy schedules.  I have been working with both the physiatrists and therapists to develop a system that will satisfy everyones needs legally and most importantly allow the therapists to have some autonomy. last night, I taught one of the therapists how to do a preoperative evaluation since post-op patients are not seen for at least 2-3 months post-op.  By this time most of the joints are frozen (something modalities will often not fix).  After having seen multiple post-op patients with frozen joints, I have developed an exercise program to be given to the patients to complete during the first 2-3 months post-op at home.  My hope is that by the time patients go to therapy, their strength and range of motion will be somewhat functional.  The physiatrists were reluctant when I proposed the idea to do pre-ops because there is already a 1-2 month wait list for physical therapy.  One of the therapists at the hospital and I explained that the patients would be finished with therapy much sooner and the wait wouldn't be as long if patients could get started with a home program in the 2-3 months before starting therapy.  I was shocked that they agreed and are willing to try it.  It seems as though the therapists are so eager to better their care but they are limited since the therapists are run by the physiatrists and the physiatrists are run by politicians.  Unfortunately, tomorrow will be my last day at Almenara. It has been fun but very tiring!

Skulls from people in Paracas-all had brain surgery
Two skulls above: Families that wanted to be distinguished shaped their skulls with sticks so they could be identified!

Who knew one could be so busy in a foreign country on a solo adventure?! I seem to have not made it home before 9 p.m. at all this week! This afternoon, my translator Ana invited me to the archeological museum, then to her house for soup this evening.  The museum was incredible.  The artifacts  told so much about the Peruvian history and Ana is so knowledgable, she should be a paid guide! Ana was born and raised in Lima and is one of six children (like myself). She told me a lot of her family history on her fathers side, from Nazca, Peru and her mother's side (from the highlands).  Two very different regions! She also told me about the terrorism from the 80's to the early 90's.  She said she would hear or witness at least 2 bombs everyday.  She had to replace her windows weekly.  She said the country is corrupt and she really cannot trust anyone.  I went to her house after and had a wonderful chicken soup.  Her roomate, Mary was there and they both lead fascinating lives.  Inside their home was a small room.  This is the room where Mary fabricates ALL of the braces, bolsters, exercise mats, raised toilet seats etc.  She is not paid by the hospital system but all of the therapists have her card and they call her when they need something fabricated.  She showed me many photos of things she has made.  She is one talented woman! She was at her sewing machine making a straight leg brace out of hand cut PVC piping, velcro and a thin piece of padding.  She said she sells a straight leg brace for 50 sols (about $15) and is in the business to make braces people can afford.  She comes to the hospital (or patients home), takes the measurements and has the brace made in a week.

Mary, Ana and I at Ana's house

Mary a her sewing machine making a straight leg brace

Ana and Mary-Ana's bike 1950's, Mary's banana seat 

Teaching is going well at Hospital Almenara.  It is a bit more frustrating because of the fact that PT's and students have to come and go during the lab to treat patients.  Seems like I explain one technique and right after 5 more people will arrive! I did come up with a good solution though-I picked four of the students that seemed to really grasp all of the techniques and had them teach in small groups.  Seemed to be very effective.  One of the PT's came up to me today and told me she tried one of the techniques right after she learned it on a patient and that was the first time in 2 months the patient had been painfree.  She was VERY excited, and I was very happy to see the PT's applying the skills.  I had an adorable elderly patient this morning that had an anterior dislocation 5 months ago.  This was perfect since one of my talks is on glenohumeral joint instability.  She just smiled and said 'thanks to your treatment I can move my arm.' I think she hugged and kissed me 10 times before she left.  The looks on the patients faces and their thanks after I treat them is honestly better than a paycheck.  I brought Theraband that I had saved from patients and scraps.  Ana had this in a double black plastic bag so that nobody would take it and locked it in her locker.  She organized it so that each group of students got 4 pieces.  They were so excited, they could not stop hugging me.  I think what I might do is continue to have patients return any unwanted Theraband and save it for those that really need it.  So many patients will go through 5 different colors, and most of them throw it away when they are done-this is cherished by the hospitals in Peru.  Tape cost $50 per roll to get in Peru since it is imported.  We used duct tape today since it can be bought off the street for $5.

A 'Mulligan belt' one of the students made out of a bike tube! 

Students practicing shoulder taping using duct tape

This patient is adorable!! she is trying out the Theraband I brought-patients love it!

The arm bike is handcrafted out of a chain ring!

Teaching the students about osteoarthritis

A new mobilization?!

'You pay 25 sols or no backpack'...

Finishing my story... I had just returned from Ballestas Island on Sunday.  A wonderful start to the day and nothing but great visions of beautiful scenery and sand-boarding ran through my mind as I boarded the 15 passenger van for Huacachina.  I sat next to a girl from France.  She said she had to get back to Lima that evening but was unable to get a bus because of the election (it is a mandatory vote in Peru and there are severe consequences for those that do not vote). Therefore, there were many people scurrying from district to district to vote.  She said the driver said he would drop her on the highway and someone would pick her up. Sounded a bit freightening to me, but we pulled over and the driver waited 30 minutes with her flagging every bus that went by until a bus that had a spare seat finally stopped.  I have been more than impressed by how people go above and beyond to help in Peru.  If you are still following this story you can rest assured it gets much better.

So, I arrived in Huacachina at noon on Sunday.  I thought I would arrive and head straight into the dessert with my English speaking guide.  I was wrong.  They set up my reservation for 4 p.m. My 'English speaking guide' Patricia arrived and said 'this is Huacachina, you have 4 hours until your ride, get lunch or whatever, I have to go back to Ica to meet a group.'  So, as quick as I could say 'mucho gusto' she was gone.  I hiked up the tallest sand dune and thought I was going to collapse-imagine hiking a very tall mountain in thick sand!!!! It was a beautiful view.  I could see the entire town of Huacachina.  I got some lunch and stuck my feet in the oasis.  Met some cute kids there from Arequipa.  They were learning some English in school and were excited to show me that they could count to 15.  They motioned for there mom to come down and introduced me to her.  Brien said 'this is Jennifer, she is  American!' He was so excited, he wanted his mom to take his photo with me and his sister! The mother also wanted her photo taken with me.  The Peruvian children (and adults) seem to be very excited to interact with people from the U.S.
I met at 4 p.m. at the restaurant as I was instructed.  There was a large group also heading into the dessert, only they were there to stay for awhile.  There was a man loading all of the bags into one of the dune buggies.  He grabbed mine, and, assuming this is what everyone did, I did not resist.  When I realized I was going in a different buggy than the one my bag was in, I asked if they were certain I would get it as I had a close connection with the bus back to Lima (we were to arrive at 6 p.m my bus departed at 6:30).  'don't worry, don't worry.' I think I have heard this phrase before... I even went as far as asking the only guy that spoke some broken English to ask the driver if it was OK that my bag was in a different buggy.  He replied, that is what we do.  I felt reassured.  The dune buggy driver was crazy (loco as they call it in Spanish).  He had a look on his face as he was driving that I will never forget! It was not a look of oh this is so fun, it was a very intense stare, with a tight grip on the wheel and his head forward.  He was going so fast that we were catching air over the sand dunes.  I remember one very vividly.  He stepped on the gas, we went over a small dune, then over a small lip-he did not slow down at all; I looked down and there was a huge drop off (some of the sand dunes are 300 ft).  It was like the Dukes of Hazard.  We caught air and landed on a dune on the other side.  Everyone was a bit shocked, then a few nervous laughs came out.  I think we were all a bit relieved when he stopped and we got to go sand-boarding.  This was great fun-some went on their stomachs, some stood.  I tried both ways and it was awesome! It was much faster than snow, which I appreciated.  I was amazed at how similar it was to snow boarding.  The runs were very long and the only differences were that you had to take a dune buggy instead of a lift and it was sand instead of snow.  We stopped 5 or 6 times to board, watched the sun set and after 2 hours, returned to town.

The town of Huacachina-population 115

Brien and Dianna

Sand-boarders on the steeps

The locals going for a Sunday row.

Although it was a fun day, I was ready to head back to Lima, where my surroundings have become familiar.  We arrived at 6:00.  Perfect timing, I thought.  My cab driver was there ready to drive me to the bus station.  Only one problem.  My bag was not there.  I asked the driver where it was he replied 'poccito inglis'  another familiar phrase! I ran ahead a bit and asked the man that knew a little English if he could help me ask where my bag was.  The driver said it must be in the garage.  She he motioned for me to get in the buggy.  I searched 4 buggies and no bag.  It was 6:10.  I tried to tell him not to worry about the bag, I would leave it behind so I could catch the last bus for the evening to Lima. One more problem.  My bus ticket was in my bag.  I couldn't go anywhere without it.   The guy that spoke some English could sense the frustration and stayed to translate since time was running low.  He again, told them the driver put my bag in the buggy with the large group.  It finally clicked and the buggy driver said 'your bag is in the middle of the dessert.'  All the drivers were talking and I had no clue what they were saying.  The one phrase I did pick up was no soles, no backpack.  They wanted money for gas before going to the dessert to get my bag, even though they repeatedly said 'no worry'.  He wanted 25 sols-I had only 20 on me (10 for each cab needed to get home).  Guess where the rest was.  Yup, in my bag (although I was smart enough to not keep much in there.) The man that spoke some English was nice enough to come the second time the man motioned for me to come in the buggy.  I thought we were going back to the restaurant where we congregated to board the buggies.  Instead, he stepped on the gas (on the dirt road at this point) swerved to miss 3 dogs in the middle of the road, honked the horn to alert the children in the road to get out of the way (they jumped in the ditch to avoid getting hit) and took off in the pitch black into the middle of the dessert.  I have done a few crazy things in life, but I can honestly say, I have NEVER been so scared! I frantically tried to get my seatbelt on but it was jammed.  The guy that was nice enough to join me could not get him on either because of the speed and rocking from the dunes.  I heard him say a quick prayer under his breath.  Sand was flying in our eyes, we began getting air off of the dunes, and our stomachs felt as though we had just gone down the worlds steepest roller coaster-the excitement that we once felt during the day had vanished.  We were both scared.  20 minutes later, we arrived at a large group of folks sitting by a campfire.  My bag was in the middle.  I ran as fast as I could, grabbed the bag, and yelled gracias as I ran back to the buggy.  Looked at my watch, 6:25.  I was certain I had missed my bus.  Got down, cab driver was still waiting.  he said 'rapido' and did not seem to worry about going 90 mph on a residential street to get me to the bus station.  I ran from the cab to the bus station as it was pulling away.  I motioned for it to stop and was very thankful they let me on.

Some sand-boarders from my group

Dune Buggy

My first attempt at sand-boarding!

Huacachina with town of Ica in distance

A Huacachina sunset

'You pay 25 sols or no backpack'...

Finishing my story... I had just returned from Ballestas Island on Sunday.  A wonderful start to the day and nothing but great visions of beautiful scenery and sand-boarding ran through my mind as I boarded the 15 passenger van for Huacachina.  I sat next to a girl from France.  She said she had to get back to Lima that evening but was unable to get a bus because of the election (it is a mandatory vote in Peru and there are severe consequences for those that do not vote). Therefore, there were many people scurrying from district to district to vote.  She said the driver said he would drop her on the highway and someone would pick her up. Sounded a bit freightening to me, but we pulled over and the driver waited 30 minutes with her flagging every bus that went by until a bus that had a spare seat finally stopped.  I have been more than impressed by how people go above and beyond to help in Peru.  If you are still following this story you can rest assured it gets much better.

So, I arrived in Huacachina at noon on Sunday.  I thought I would arrive and head straight into the dessert with my English speaking guide.  I was wrong.  They set up my reservation for 4 p.m. My 'English speaking guide' Patricia arrived and said 'this is Huacachina, you have 4 hours until your ride, get lunch or whatever, I have to go back to Ica to meet a group.'  So, as quick as I could say 'mucho gusto' she was gone.  I hiked up the tallest sand dune and thought I was going to collapse-imagine hiking a very tall mountain in thick sand!!!! It was a beautiful view.  I could see the entire town of Huacachina.  I got some lunch and stuck my feet in the oasis.  Met some cute kids there from Arequipa.  They were learning some English in school and were excited to show me that they could count to 15.  They motioned for their mom to come down and introduced me to her.  Brien said 'this is Jennifer, she is  American!' He was so excited, he wanted his mom to take his photo with me and his sister! The mother also wanted her photo taken with me.  The Peruvian children (and adults) seem to be very excited to interact with people from the U.S.
I met at 4 p.m. at the restaurant as I was instructed.  There was a large group also heading into the dessert, only they were there to stay for awhile.  There was a man loading all of the bags into one of the dune buggies.  He grabbed mine, and, assuming this is what everyone did, I did not resist.  When I realized I was going in a different buggy than the one my bag was in, I asked if they were certain I would get it as I had a close connection with the bus back to Lima (we were to arrive at 6 p.m my bus departed at 6:30).  'don't worry, don't worry.' I think I have heard this phrase before... I even went as far as asking the only guy that spoke some broken English to ask the driver if it was OK that my bag was in a different buggy.  He replied, that is what we do.  I felt reassured.  The dune buggy driver was crazy (loco as they call it in Spanish).  He had a look on his face as he was driving that I will never forget! It was not a look of oh this is so fun, it was a very intense stare, with a tight grip on the wheel and his head forward.  He was going so fast that we were catching air over the sand dunes.  I remember one very vividly.  He stepped on the gas, we went over a small dune, then over a small lip-he did not slow down at all; I looked down and there was a huge drop off (some of the sand dunes are 300 ft).  It was like the Dukes of Hazard.  We caught air and landed on a dune on the other side.  Everyone was a bit shocked, then a few nervous laughs came out.  I think we were all a bit relieved when he stopped and we got to go sand-boarding.  This was great fun-some went on their stomachs, some stood.  I tried both ways and it was awesome! It was much faster than snow, which I appreciated.  I was amazed at how similar it was to snow boarding.  The runs were very long and the only differences were that you had to take a dune buggy instead of a lift and it was sand instead of snow.  We stopped 5 or 6 times to board, watched the sun set and after 2 hours, returned to town.

The town of Huacachina-population 115

Brien and Dianna

Sand-boarders on the steeps

The locals going for a Sunday row.

Although it was a fun day, I was ready to head back to Lima, where my surroundings have become familiar.  We arrived at 6:00.  Perfect timing, I thought.  My cab driver was there ready to drive me to the bus station.  Only one problem.  My bag was not there.  I asked the driver where it was he replied 'poccito ingis'  another familiar phrase! I ran ahead a bit and asked the man that knew a little English if he could help me ask where my bag was.  The driver said it must be in the garage.  She he motioned for me to get in the buggy.  I searched 4 buggies and no bag.  It was 6:10.  I tried to tell him not to worry about the bag, I would leave it behind so I could catch the last bus for the evening to Lima. One more problem.  My bus ticket was in my bag.  I couldn't go anywhere without it.   The guy that spoke some English could sense the frustration and stayed to translate since time was running low.  He again, told them the driver put my bag in the buggy with the large group.  It finally clicked and the buggy driver said 'your bag is in the middle of the dessert.'  All the drivers were talking and I had no clue what they were saying.  The one phrase I did pick up was no sols, no backpack.  They wanted money for gas before going to the dessert to get my bag, even though they repeatedly said 'no worry'.  He wanted 25 sols-I had only 20 on me (10 for each cab needed to get home).  Guess where the rest was.  Yup, in my bag (although I was smart enough to not keep much in there.) The man that spoke some English was nice enough to come the second time the man motioned for me to come in the buggy.  I thought we were going back to the restaurant where we congregated to board the buggies.  Instead, he stepped on the gas (on the dirt road at this point) swerved to miss 3 dogs in the middle of the road, honked the horn to alert the children in the road to get out of the way (they jumped in the ditch to avoid getting hit) and took off in the pitch black into the middle of the dessert.  I have done a few crazy things in life, but I can honestly say, I have NEVER been so scared! I frantically tried to get my seatbelt on but it was jammed.  The guy that was nice enough to join me could not get him on either because of the speed and rocking from the dunes.  I heard him say a quick prayer under his breath.  Sand was flying in our eyes, we began getting air off of the dunes, and our stomachs felt as though we had just gone down the worlds steepest roller coaster-the excitement that we once felt during the day had vanished.  We were both scared.  20 minutes later, we arrived to find a large group of folks sitting by a campfire.  My bag was in the middle.  I ran as fast as I could, grabbed the bag, and yelled gracias as I ran back to the buggy.  Looked at my watch, 6:25.  I was certain I had missed my bus.  Got down, cab driver was still waiting.  He said 'rapido' and did not seem to worry about going 90 mph on a residential street to get me to the bus station.  I ran from the cab to the bus station as it was pulling away.  I motioned for it to stop and was very thankful they let me on.  Overall, I would say it was worth it.

Some sand-boarders from my group

Dune Buggy

My first attempt at sand-boarding!

Huacachina with town of Ica in distance

A Huacachina sunset