Images from Santa

Goodbye celebration with the whole gang.

On a walk through the rain forest with friends.
Bringing our snake bite patient from Rumi Tumi to Santa.
Learning to tell the difference between Malaria Falciparum and M. Vivax.
On the way back from the discoteca, only to find out that there was a repeat C-section waiting for us at the center.
The town motor broke, so there was no electricity for 2 days in a row, but that didn't stop us from going out.

A Conversation with Father Jack

I had a chance to sit down with Father Jack once he came back from his trip to ask him a little bit about what he'd like to see for Santa Clotilde in the future and I'm going to try and sum it up...

• He'd like someone to take over as medical director. He's 65 and has a heart condition, he's ready to hand over the reins, but hasn't had any takers. The Peruvian doctors tend to stay for a few years and then move on.
• He'd like to develop a relationship with a bigger institution to get some more outside funding. He has been too busy running the place to tell people about Santa and fundraise. But they could use the money.
• He'd love to dedicate some more time to prevention. They provide great medical care at Santa, but they barely skim the surface of dealing with the underlying causes of some of the most common things they see. People need clean water, latrines, better nutrition. And he'd like to be able to send more people out to the surrounding communities.
  

So, any takers?

Hunger

So hunger is pretty much a steady state in Santa Clotilde. I had regular lunches, the ability to go out and buy food every day and still felt pretty hungry most of the time I was in Santa. What I experienced is nothing compared to what the people of Santa experience everyday.

One day after lunch, I asked what people in Santa and the surrounding communities ate normally. I could guess from what I got served that it involved a lot of bananas and yuca. The answer was, that most people were lucky if they ate one full meal a day. They mostly sustained themselves on a diet of Mazato, a local drink that is made of yuca that is mashed and then chewed and spit out and fermented. I have a really hard time thinking about drinking anything that involves something that someone spit out, but in Santa and on the Napo it is a staple. They say that they'll drink this for breakfast and take it with them to their farms and drink it continuously throughout the day to feel full. Then when they come home in the afternoon lunch is either some other form of yuca, or a form of banana and maybe rice or fish (depending on the season). Not a whole lot of protein in the diet. Yuca is a starch and banana is a banana. Buying food in the markets was more expensive than you'd think, b/c of the costs of transporting things all the way to Santa.

I started asking people if they ate well and they always said yes, but if you asked them if they felt they had enough to eat, most people would say no. There is a supplemental nutrition program provided by the government to families with children under the age of 3 and to pregnant women, but includes only a couple of bags of rice, some oil, sugar, and few cans of milk. Not much to make a dent in improving the nutrition of these families. This problem is much bigger than anything we can fix on a clinic visit.

The ones you can't save

I had mentioned in an earlier blog that we had an 8 month old come in for pneumonia and chronic malnutrition. So the first photo is of Roberto, when he came in, weighing 4.2 kilos, lethargic, dehydrated, but at the time with no fever or respiratory symptoms. We went ahead and treated him for a possible pneumonia and sepsis with heavy duty antibiotics (Ceftriaxone). He had a rough time at first, but then progressively got better.








And after a little more than a week, he looked good enough to go home, eating well and had gained a couple pounds.

So we were all surprised when he returned to the center 3 days after his discharge with fever, diarrhea, and this time really junky sounding lungs. Well, now we were flat out of Ceftriaxone, so we put him on what we thought were the best combination we had, but this time it didn't work, he just got worse and worse and 3 days after he came in he died. I'm not used to seeing kids die and this was particularly hard, b/c I had seen him get better and we don't know what happened. This is the second child this mother had lost to a severe pneumonia.

The other patient we lost died right after I left Santa. Her name was Rosa, she was a 35 year old woman who had become paralyzed from the waste down after a tree had fallen on her during a storm. She was doing ok until she got pregnant and then during her pregnancy developed awful bed sores (stage 4 decubitus ulcers). The family took her to their local health post when her sores were very bad and they sent her to Santa. When she arrived it was clear that her sores were severe, her nutritional status was poor and Rosa was severely depressed. She too suffered from our shortage of ceftriaxone. She had some good days, but ultimately, I think Rosa became septic and didn't have the reserve to be able to fight the infection.

These patients, stay with you, always wondering what you could've done differently, how much difference would it have made to have more technology, more medicines, no way to know.

Catching Up

So I pretty much took a break from writing in the blog during my last week in Santa. Now I'm in Puno for the festival de la Candelaria and while I'm resting to adjust to the altitude thought I'd catch up on this blog.

So my last week in Santa was jam packed with a busy call, a trip out to a distant community to pick up a patient, lots of interesting discussions, dancing, and the sad loss of a patient. So where to start....

My last call was filled with three semi-emergencies, but thankfully they all happened before 11pm. The first was a 3 year old girl that took a 3 meter (just over 9 feet!) fall right onto her head and per her mom had lost consciousness for a few minutes. Luckily they brought her right in and she was awake and screaming...and it was a good sign that every time I came near her she tried to push me away with both her arms and legs. There wasn't a whole lot to do, except observe. I checked her complete blood count....mostly to have a baseline in case later she showed signs of internal bleeding. After a few hours and some ibuprofen she was much calmer and was able to go home the next day.

The next patient that rolled in for me was, Cristian, a 14 year old boy who had a generalized seizure while working out in the country with some family and friends. One of the medical assistants who works at the center had been out there with him and she witnessed the seizure. She told us that it lasted almost 20 minutes and she was really afraid he was going to die. He'd never had a seizure before, so it was particularly scary for his family. When he arrived at the center he was post-ictal (the sleepiness that comes after a seizure), but he was able to answer my questions and move all his extremities. My main goal for him was to prevent him having any more seizures. Finding the cause for the seizures would be much more difficult. Thankfully the clinic has dilantin, but there are no automatic IV pumps, so with the help of one of the Peruvian docs we figured out how to dilute the loading doses and how fast to run them. I definitely want to get better at figuring out dilutions of medicines, preparing IV fluids, etc. It's crucial here. Anyway, I made my nice list of possible causes for his seizure and that was pretty much the extent of his work up. We ruled out meningeal malaria, he didn't have any signs/symptoms of infection, and his CBC looked good. There is no CT scanner or EEG and no one could say that he would definitely get either of these if he went to Iquitos. He also had a heart murmur which may or may not fit into the whole picture. Anyway, he didn't seize anymore and we sent him home the next day on oral dilantin. His family was going to see about going to Iquitos to see a neurologist.

The last emergency patient I had come in was a man in his 60's who was brought in lethargic and semi-responsive. His family had brought him by canoe to Santa from a village 4 hours away. I hated the thought of that man being on a canoe in that condition. When he arrived he was too weak to move himself from the stretcher to the bed and he was semi-responsive to my questions. We found out that he had had pretty bad diarrhea for about 5 days and then as it was settling down he decided to take a "natural purging solution" to cleanse out his system. Not a good idea! So then he started to vomit everything and couldn't stop. Thankfully his family brought him in, b/c 5 days of steady fluid loss is bad. Anyway, all we did for him was hydrate him and give him some anti-nausea medicine and it worked. And told him to never take another purging solution ever!! He was able to go home the next day as well.

So that's it my last call!

Just some random thoughts

Father Jack comes back from his vacation today so Iĺl be back to sharing computers with everyone else and probably won't be writing as frequently in the blog. We had two beautiful, incredibly hot sunny days followed by the best thunder and lightning storm I've ever seen. The sky was this amazing orange-yellow. Now we are back to our usual cloudy humid days.

Last Friday, there was a staff meeting and they discussed the difficulty they are having collecting statistics from all their health posts on the Rio Napo. MINSA requires each health center to turn in monthly statistics on the patients they've seen, especially about malaria cases, TB cases, vaccines, and for their nutrition program. The workers at the health post don't see the value in the information and the forms are time consuming. I'm sure the data collection is tedious, but it's so important from a public health standpoint. To know what's going on to be able to deal with it effectively. And on a much more practical level it can affect the amount of money, medicine, or employees that get put towards a certain disease or area. But the reality is no one likes to do paperwork. There was no clear solution they came up with, but to discuss it again once Fr. Jack returned.

I'm on call again tonight. My little boy with chronic malnutrition and pneumonia gave us a bit of a scare last night, droping his oxygen levels down into the 80's but he's doing better today. Hoping to get some rest so I can watch some of the Obama inauguration online tomorrow. Yay!

A few more patients

As I was on my way out for a walk along the river I decided to stop by and see what was going in the hospital. Jorge was on call and a 15 year old had just arrived who had been shot in the foot by a animal trap! It's some kind of contraption that is rigged to a bb-gun and he had accidentally walked into the trap. There was a small chunk of the right side of his foot missing, you could clearly see a few of his tendons, but bone wasn't immediately visible. I put on a pair of gloves and started to help Jorge. Once we were sure he was stable we decided to irrigate the wound and take a good luck. As you can imagine, it was pretty painful, so Jorge decided to sedate the kid with Ketamine, the wonder drug. While he did that the nurse and I cleaned the wound to try and get a better idea of what had been damaged and to control the bleeding. Once we did that we put a pressure dressing on his leg and started working at setting up a transfer to Iquitos. The wound continued to bleed so about an hour later, we took him back to the OR and Jorge ligated one of the veins that was bleeding and was able to find one of the bb pellets. He continued to ooze, but there was nothing else we could find to ligate. So we dressed the wound again and hoped for the best. He left for Iquitos the next morning with one of the nurses and there they were able to do an xray and said his foot is full of bb-pellets. They were planning on taking him to the OR to see what they could do.

We have two other patients in the hospital I wanted to make sure and mention. One is Holbert, a 11 year old boy with aplastic anemia. Aplastic anemia is a pretty serious condition where your bone marrow doesn't produce enough of the blood cells you need. It can be life threatening. He was diagnosed a few years ago and was on immunosuppressive therapy for a year and did well for a while, but then relapsed this year and has been at the hospital for the last four months getting occasional blood transfusions and antibiotics. He is from a community that is far from Santa Clotilde so it is safer for him to stay at the hospital than to go home. He is in need of a bone marrow transplant and so he waits with us.

On Thursday afternoon, in clinic, a mother brought her 8 month old son because of a fever and cough for 3 days. When I looked at him I had to double check the date of birth, because he looked like a 3 month old, weighing only 4.2kilos (9lbs). I have delivered babies in the states that weigh 9lbs! The mother told me that for 3 days he had had fever, cough, some vomiting, and diarrhea. She said that he had stopped breastfeeding at 5 months and she was supposed to be getting milk from the nutrition program at the health center, but hadn't received it steadily and the child ate very little other food. She has 5 other living children, one child died at the age of 6 months from pneumonia. She is a single mother and her only income is from what she raises on her chacra. As I examined the child he was truly lethargic (something you rarely see in the states) and had all the classic signs of severe dehydration and an awful fungal rash that had gotten super infected. It broke my heart. This mom clearly cares for her child, but she just does not have the resources to take care of him well. I admitted him for IV hydration, antibiotics, and feeding. So far he's doing well and eating like a champ, not sure how long we'll keep him, but the nurses have already set up extra food supplies for the mom and baby.

Senora Nelly

I was on call the other night with Senora Nelly a tecnica (like a medical assistant) that has been working at Santa for 22 years. She is by far the best tecnica in the center. She knows how to do everything, knows where everything is, and the doctors often ask for her opinion during procedures. While we were sitting I asked her how she came to work at Santa and she told me a great story.

Sra. Nelly is from a comunidad (small town) about 3 hours from Santa by canoe. She only completed grade school because her parents did not have enough money to send her to high school. So at about age 12 she started working with her parents on the chacra (farm). When she was young she got pregnant and had her first son. She said that at first he was fine, but when he was about 7 years old she noticed that he ate all the time and didn't gain any weight. She had taken him to health posts before but he was always just treated for parasites. He then started to wake up frequently at night to pee. She had heard that there were some gringo doctors in Santa Clotilde so she decided to bring her son.

She said at the time it was just Padre Jack and Padre Mauricio. They saw Padre Jack and he asked them to stay the night so he could do some tests and observe the boy. He asked her to collect the urine overnight and in the morning the Father Jack said he had a pretty good guess why the ants were so attracted to her sons urine. They went on to diagnose him with Type I Diabetes and started him on insulin. They asked her to stay at the hospital while they started treatment, made sure he started to get better, and taught her how to give the insulin. The initial visit stretched into three months. She said that at first she would help clean around the center, but after a while she got bored and since the Fathers had no one else to help them she asked if she could help them give medications. She said, if they would label them, she would give them. They said yes. And then slowly she asked for more and more responsibilites. She asked them to teach her how to take blood pressures and she said it took her a while, but that padres were very patient and she learned. Finally, she decided she must go back to her village and help her mom back at the chacra...so she went with a cooler to keep the insulin cool and went back to working at the farm and selling their vegetables.

A few months later she got a letter from Father Jack asking her to come back to Santa and work for them. They would give her a position as a tecnica and train her. She said it was tough to leave her family, but knew there would be more opportunity for her and her son if she had a job that had a steady income. So she came to Santa and has been here since. She said that she learned everything from the Padres and reading the book "Where there are no Doctors". She now has 4 other children, 1 of which is now in college studying computer science.

She hopes the others will go to college as well, but it is expensive and she wonders what they will do with so much education. There are no jobs in Santa. She says that it is sad to see the kids finish high school and then have to return to the Chacra anyway. The main source of income for people here is agriculture. It's very small scale...pretty much enough to sustain yourself. The distance and cost to get to Iquitos are prohibitive for most people. The only other industry which is growing in this area is Petroleum companies and most are skeptical about their social and environmental impact. Even with these obstacles she still hopes for her kids to go to college in Iquitos, porque solo con hacerse uno profesional puede tener esperanza de dejar la chacra.

Tienes Aseguranza?

Do you have health insurance? A question that is as important here as it is in the US. Sta. Clotilde is unique because patients are seen regardless of their insurance status or their ability to pay. Father Jack says that everyone who doesn't have insurance gets a bill, and they can pay that bill in whatever way they see fit...chickens, bananas, working at the clinic, or with cash. You will see many of the family members of our hospitalized patients that come from far away doing odd jobs around the health center.

Peru has several parallel health care systems...there is the public system (MINSA) which serves the vast majority the population, there is also the social security system (ES SALUD) this is for all those who are formally employed, there is a military health care system for those serving in any branch of the armed forces, and then there is a whole slew of private providers (hospitals and clinics). The Sta. Clotilde health center is part of the MINSA network. The vast majority of patients that come here are covered by the Seguro Integral de Salud (SIS). SIS is a program that covers clinic visits and hospitalizations for the poorest families in the country.

SIS is good because it gives people access to health care, but it comes with many limitations. One major one is that it is primarily focused on acute/reactive medicine. It does not cover some chronic diseases. I haven't figured out which ones it does and doesn't cover, b/c here they take care of everything regardless of your diagnosis. The SIS formulary is also pretty limited. And probably it's biggest weakness is how much they reimburse the center for the work they do. The center gets paid 12 soles (US $4) for each patient visit...but the patient cannot come to the clinic for the same thing twice in one month, so the doctors twist their diagnoses to meet this limitation. That 12 soles covers the doctor visit, the medications, and any procedures that are done. Ultimately the center ends up losing money...b/c these things all cost more than 12 soles. Here they don't charge patients for supplies when they do procedures, but at other health centers patients are often asked to buy their own gloves, needles, IV bags. For patients that are hospitalized the center gets 80 soles (US $26)...regardless of the diagnosis, how long they stay, or what supplies are used. It's impossible to fully fund everything that needs to get done this way. Because Sta. Clotilde is partially funded by the Catholic church they do not charge patients for anything except for an occasional medicine that's not on the formulary and even these prices are symbolic. The Peruvian government has just made a pledge to provide universal healthcare by 2011, but it will not be able to do this well without making a significant financial committment...keeping my fingers crossed.

Who works here?

I'm on call again tonight, but it's currently pouring rain, so I should be patient free for a while. I've spent some of my first two weeks here trying to figure out how this health center fits into the bigger Peruvian health care system.

Santa Clotilde is pretty unique because it is a partnership between the Catholic Church and MINSA (the ministry of health). So Father Jack is the director of the health center but he is an employee of the church and not the ministry of health. This is huge, because it has offered Sta. Clotilde (Santa) continuity. My understanding is that for other areas of Peru, the directors of health care systems are often political appointees and so there can be a lot of turnover. The employees here are a mix of those employed by the church part of the health center, others employed by the MINSA part of the health center, and those given contracts by the local government. Not sure who's employed by whom, but it mostly seems to work.

The medical providers tha work here come from all over Peru. There are 4 Peruvian doctors that work at Santa...none are planning on staying for more than a few years and none are from Santa. One of the docs is doing his Serum...this is a year of service that all doctors and nurses must do after they finish medical school. He is from Iquitos and is plans to go work somewhere else before doing a residency. There is another physician that is contracted by the church and she's been here a year and will likely stay another year, before she heads back to Lima to try and get a residency spot. The 3rd doc was contracted by the city council and has been here 6 months...he's not sure how long he's staying, he hasn't been getting a steady paycheck, which doesn't help. He also aspires to find a residency spot in Lima. The 4th doc is also from Lima and is on vacation right now for his wedding, but my understanding is he'll be here two years. Our midwife is contracted by the church and she's been here a year, but also plans to return to her hometown. All the docs say this is a great experience b/c you get to manage cases you wouldn't in a big city, but they all want, understandably, to be closer to home and to more opportunities for their families. It underlies how difficult it is to find physicians who are willing to stay in a rural setting without giving them some real incentives. I don't know how much the doctors make here...but it's not enough to compensate from being far from their family.

La Guardia/On Call

I've been on call twice so far here and they are definitely a different experience. Call starts right after lunch which is at about 3pm. You are responsible for seeing patients that come in for consults and the hospitalized patients. People are supposed to come in only for emergencies, but the definition of an emergency is pretty liberal.

The first patient that came in on my first call was a little 3 year old boy that came in with severe abdominal cramps. He had had a fever the day before, had pain localized around his belly button, no appetite and his belly was distended and pretty painful on exam. So, thinking in emergency mode, I thought, I have to rule out appendicitis. Fine, except that from 2pm - 6pm there is no electricity, so that meant no blood or urine exams until 6pm and then there is no CT to rule in or out the diagnosis, just a purely clinical diagnosis. And then I didn't really want to think about what we'd do if he actually had appendicitis. Padre Jack is in Iquitos right now, so no one here that can do an appendectomy. Anyway, I kept him NPO (no food), started him on triple antibiotics (for the worst case scenario..a ruptured appendix), and started serial abdominal exams while I waited for the electricity and at least some lab results.

At about 10:30pm that evening when I went to check on the little boy the nurse asked me to check on one of the patients that had been there for a blood transfusion. This is a 42 year old woman who had a kidney transplant about 5 years ago and is again having chronic kidney failure. So, as part of her kidney disease she has chronic anemia and her blood count had dropped enough that she was symptomatic from the anemia. A decision was made to give her 1 unit of blood. The plan had been for her to go home after the transfusion, but the nurse noticed she was breathing with difficulty. I went to evaluate her and she was in fact feeling very short of breath, when I listened to her lungs she was clearly fluid overloaded and the swelling in her legs confirmed this diagnosis. We checked her oxygen saturation and it was 87%, which is not good. Normal is 100%. So we decided to go ahead and admit her and get her some oxygen, which had to be rolled in from who knows where....and we needed to get the fluid off of her. So I started by asking for 20 mg of Furosemide - a diuretic medication that helps you pee out excess fluid- IF your kidneys are working. It usually works pretty fast, so we waited to see if she would pee. Meanwhile at 11pm sharp the electricity turns off and we are doing the rest of our work by lanterns. If I didn't have a sick patient, I'd say the whole look is very quaint, but when your patients 02 saturation won't go up...not so fun to be sitting there in the dark with your lantern and flashlight. Anyway after another 40mg of IV Furosemide and much worried waiting and increasing levels of oxygen the patient finally pee'd and felt started to breathe more easily. Deep breath...the rest of the night was calm, but we were then left with what to do with this patient. We can check her Creatinine (a level that tells us how her kidney is functioning) and so we know she needs dialysis, but we can't check any other electrolytes, so we can't monitor anything else that could potentially go wrong, which is a lot and there is no nephrologist or hemodialysis here. Luckily she's continued to be stable as the doctors have pressed for her to get accepted for a consultation with a nephrologist in Iquitos and she'll be going tomorrow.

The little boy with the abdominal pain eventually had a bowel movement and was tested for parasites and had both giardia and ascariasis and when treated had quick resolution of his symptoms. Good time to remember the saying in medicine, "common things are common."

I was on call again last night and it was quiet. We have only one other potentially unstable patient. He is a young man who has cirrhosis and has esophageal varices (swelling of veins in his esophagus that are prone to bleeding). He has surgery for this about a year ago, but he has presented twice since the surgery vomiting blood. And he did again yesterday....luckily it wasn't much and he hasn't vomited since he got here. We transfused him and are just trying to keep him on his medications, there's really no other way to treat him. We did find a medicine that is used in the US for esophageal variceal bleeding, but it's only supposed to be used with an IV infusion pump, which we can't do here, so not as helpful as you'd think to actually have the medicine. Anyway, hopefully he won't bleed anymore. I'm more than a little relieved when my calls are done....I have a great deal of respect for the work that the physicians do out here with what they have and I love that I have consultants to work with back home.

Los Pacientes de Sta. Clotilde

You see everything here! My bread and butter: diabetes, hypertension, arthritis, chronic kidney disease...it's all here, but there are few of those patients. The most common things they see here are Malaria (both Vivax and Falciparum), infectious diseases...all kinds of GI parasites, TB, upper respiratory infections, and chronic malnutrition. Everyone that comes in to the center complaining of a fever gets tested for Malaria...it's basically a vital sign. There are some patients that have been treated for Malaria 19 or 20 times. The lab guy said he'll give me some Malaria slides to bring back to the states...an unexpected souvenir. And since I've been here we've been seeing a lot of Dengue Fever, which they say is strange b/c it's not endemic to the Napo, but is in Iquitos. Needless to say, I'm pretty much soaked in bug repellent.

It's been an interesting week in the hospital...
We had two infants with 2nd degree burns. One walked right into the flame that her his mom used to cook and the other was a hot water scald. I have pictures of one of the girls which i will try to post...awful. It was her whole face and part of her back. They both got antibiotics, IV fluids, and dressing changes and are both now home. The team asked me, how we managed serious burns...ha, um...I'm don't...thank god for ERs and burn centers.

Then there is little Vlademir who is a 7 year old boy who came in with osteomyelitis of his L elbow and R leg. There is no imaging technology here, so it's pretty much a clinical diagnosis. The day I arrived they had peformed an osteotomy under sedation w/Atropine and Ketamine. Ketamine is their anesthetic of choice here...it's the only anesthetic used. 2 days later, Padre Jack went back in to extend the incision a bit for better drainage and I saw the opening into the bone. I've never seen this procedure before, probably b/c we don't see a ton of osteomyelitis in the US that gets to this point, apparently pus oozed out of this kids bone. Anyway, he's doing great...fever free for the last 3 days and now he's with us for the next 4 weeks for IV antibiotics.

Lastly, I'll mention Ms. Luz...a little girl who has Pertussis, otherwise known as whooping cough. She's got the classic whoop at the end of these awful coughing fits. It's impressive to see the classic presentation of a disease, but at the same time it sucks b/c although she's on the right antibiotic it just takes time to get through the worst of it and even though her whole family should get prophylaxis they won't b/c there is no way to prove it's pertussis and the insurance won't pay for the medicines without proof. Sounds familiar...

Centro de Salud Santa Clotilde

I've been in Santa Clotilde for 1 week now and have just finished my first week of work at the health center. The Centro de Salud Santa Clotilde (CSSA) is the only health center on the Rio Napo. There are health post in other towns but this is the only health center. A health post is staffed only by a nurse or a medical assistant. CSSA therefore gets referrals from these health posts and patients will travel as long as 3 days by canoe to get here.

CSSA has a full staff, nurses, medical assistants, 4 peruvian doctors, a midwife, a dentist, pharmacy staff, and Padre Jack. Padre Jack, is basically, the jefe. He is a priest and internist by training, but he does everything...c-sections, osteotomies, dialysis. And he's been here over 20 years, totally committed to this health center, this community, and the region. As chief of the CSSA he also oversees the many health posts along the Napo River and coordinates vaccination campaigns to remote areas. The center has a procedure room, an OR, offices for outpatient visits, and a hospital with approximately 30 beds. Hopefully soon, I'll be able to upload photos.

A typical day starts with a run around the town with one of the other doctors, followed by breakfast and then it's bedside rounds at 8am. The rounds are very interactive and there is definitely an emphasis on education and wanting to learn what is being done by others, what is done in ideal conditions, and then what can actually be done here. They are constantly asking me what we would do in the states. After rounds we see patients in the consultorio. You see patients until 2pm and then your day is over. Occasionally you stay later if you admit a patient, do a procedure, or there is a delivery. Lunch is whenever your done with patients and then the afternoon and evenings are yours, unless your oncall. So, that's it....a typical day in Sta. Clotilde.

Destination: Sta. Clotilde

So, I made it to Sta. Clotilde. It's a 2 hour flight from Lima to Iquitos, the major city in the northern Amazon region. I was met at the airport by Father Maurice, a priest who was worked as a priest and a physician in Santa Clotilde since the late 1980's. He's now in his 70's and has been reassigned to Lima by the higher ups in the church. Anyway, we had a nice dinner that night with other workers traveling to Sta. Clotilde the next day and then spent the night at a dormitory that the Franciscans have in Iquitos. I didn't get to see much of Iquitos besides the plaza de Armas.
The next morning we finally headed off to Sta. Clotilde. The first leg of the journey is on the Amazon river. We took a ¨Rapido" (Fast Boat) - which doesn't leave at all quickly, we sat on the boat about 45 minutes waiting for it to fill up before we left. The ride to our first step went by quickly watching the scenery. The Amazon River is impressive...
Our first stop was Mazan, a small town, that serves as the connection point between the Amazon and the Napo River. You cross the town in a moto taxi and then we got on our private boat to Sta. Clotilde. While here, I saw my first and so far, only, pink dolphin. Our private boat was little motor boat that sat all six of us compactly and there we sat for the next 4.5 hours. We made two mini-stops before finally getting to Sta. Clotilde. To be honest, it's not the most comfortable of rides and after a while the scenery repeats itself. And there is really nothing but rainforest and water...you seen an occasional family in there canoe and every once in awhile some small hut homes. Anyway, made it!

Ano Nuevo

I couldn't watch the game here in Peru, but 2008 came to a close with a Vanderbilt win in their first bowl game since the 1950's! It might be a while before that happens again so it's a big deal for us.

We rang in the new year at a family friends house. The majority of the party goers arrived at 11:30pm and the party didn't really get started until after the New Year. Dinner was served at about 12:30am and then danced the night away until we finally came home at 6am. So, now 2009 is here and I'm off to Iquitos today and then on to the health center in Santa Clotilde.