Señor de los Milagros

Señor de Los Milagros, or Lord of Miracles, is a Peruvian cultural tradition I’ve been very fortunate to experience in my first month here. The name originated from the 17th century, where an earthquake destroyed all of Lima but left a mural of Christ (see picture) standing intact. Celebrations occur during various days in the month of October, and the streets are a flourish of purple and white balloons and processions of people following replicas of the painting with song and prayer.

My first experience of the procession occurred at the Colegio Especial (school for children with mental/physical disabilities) that I work at a few days a week. I have to preface this experience by saying that the small courtyard in the middle of Colegio can be quite chaotic, as over 100 grade school aged children attend this school. During recess I dodge balls and other playground equipment, running children, assistive devices, and the occasional vehicle in this space- and there’s usually only one class out there at a time.

That being said, last Tuesday in between patients, I was drawn out into the courtyard by religious music and prayers over a loudspeaker. There in the courtyard sat all of the children and their teachers, surrounding a moveable platform beautifully decorated in purple. It was quiet and calm and incredibly moving. Some students sang along and many participated by either carrying the platform from spot to spot or by contributing flowers to adorn it. I can’t really explain the feeling except to say that it seemed to be a small miracle in itself that there was such a spiritual calmness in the air of what is otherwise a rather disorganized chaos.

My second procession participation occurred later in the week right outside of my house! Every year this particular procession spans the entire district of La Esperanza. It, too, was beautiful and I am moved by the faith of the people here, which seems to be incredibly strong and prioritized, regardless of age- teenagers, children, and adults alike. Apparently, this procession, which occurs throughout Peru, is considered the largest Catholic procession in the world.

POCO a POCO, SE ANDA LEJOS...

My favorite Castellano expression, which roughly means “One step at a time.” Life is definitely slower here. Patience is key. For those of you who know me well, patience and a slow lifestyle are not exactly my strengths. (I can’t help but wonder if part of the reason I am here is for self-improvement in this area!) Well, I hope it works, because my patience is tested on a daily basis!

I have so many ideas for how I want to influence the healthcare system/physical therapy practice here, but it seems like there’s a mountain of obstacles. To do what I envision would involve some serious shifting of cultural norms and standards. So, I will have to learn how to be more patient and accept small successes/changes. Also, it’s important to go about everything humbly- the last thing I want to do is to come off as condescending about the standards of practice here when compared to the US.

This whole experience reminds me constantly of how lucky I am to have been born in the US and to grow up comfortably in the “land of opportunities.” I feel so fortunate to have the PT educational background that I do (not to mention all of the other luxuries I grew up with). Here, PT’s aren’t really respected- the ones in this area go to a technical school but the courses are very basic and their roles seem to be more like a PT tech than anything else. Today I was informed that they are actually mocked here and my profession is considered a job for idiots. Wow, good to know! Apparently the ones in Lima are more highly regarded.

I’ve also learned that there is an organization in Lima that has a yearly conference for PT’s, but it’s really expensive (we are talking several hundred USD per person) which could be a months pay for some! Another obstacle- this time in the form of lack of continuing education, and lack of specialists in the Trujillo area.

But- on a more positive note- I spent my morning working at Chocope Hospital (about 40 minutes north of La Esperanza). It was great to get a glimpse into a hospital setting. The care revolved almost completely around modalities, but the PT’s were fantastic- all very friendly and with a huge hunger to learn. We practiced various joint mobilizations and shared management ideas and fracture management tips. (Fractures are not generally immobilized or operated on here, so there are a lot of ugly long-term consequences.)

The PT’s requested that I organize a monthly course on outpatient conditions- and in return, they’re going to spread the word to other PT’s in this area. Our first course, in a few weeks, is on postural analysis/scoliosis exam and treatment and will be followed with light refreshments and an excursion to hear mariachi music. ☺ I’m really excited for this new development and can see it opening a lot of doors for El Proyecto this year!

Outpatient Rehab

The first few weeks of work have been a blur! It’s hard to get started as a PT working by yourself- all initial evaluations in the beginning to build up a caseload! (Not to mention, all initial evals in a foreign language, with limited resources!) I’ve put together some documents translated in Spanish- initial eval forms, patient history, versions of functional outcome tools, home exercise plans, etc. to hopefully increase the quality of care and serve as resources for other PT’s here.


For the most part, I haven’t seen anything too crazy in the outpatient clinic. My typical patient is a 30 or 40-something year old mother with low back pain. I’ve also seen a fair share of shoulders, knees and necks. Last week, however, I made my first referral- I had a patient show up at the door doubled over in severe pain, with bilateral pitting edema and a large, hard, pulsating abdominal mass. YIKES! They would not take her into the emergency room until her family had waited in line to pay the cashier in advance.


Some of the biggest challenges so far in the outpatient clinic have been…


1) “Peruvian time.”
Peruana Cosita Importante #6 – “Peruvian time” dictates that late is on time here, and it’s not uncommon to wait several hours for people to show up for meetings, outings, etc. The slower pace is nice in some ways, but can also be frustrating and can completely alter the course of your day.


I’ve tried to keep a schedule with patients but they tend to show up whenever they can or desire. The trend is that the first hour of work, the room is empty, and then everyone shows up at the exact same time- typically 3 or 4 patients ready for treatment while I’m not only in the middle of an eval, but have two other new patient evals waiting! Add a little chaotic arguing about who was there first and… It can get a little overwhelming, especially with the small physical space in the PT room and the fact that there’s no-one else there to help.

2) Lack of patient adherence - this affects home exercise programs, (lack of) lifestyle changes, patient progress and follow-up visits too. Most often the reasons appear to be economic/financial, and of course cultural. Many of my patients are illiterate which poses additional challenges.


3) Expectations about PT – because of previous experiences, many patients express that they expect a passive treatment filled with heat, ultrasound, ESTIM, infrared, and massage for every session. The concepts of regular physical activity and exercises seem relatively foreign within the population.


4) When to say no - As a new volunteer here, I’m constantly bombarded with- oh, can you take a look at me for free? Or, my _______ (insert friend, relative here) has a really bad _______. For my friends from school, this is something we get all the time, right?! But, it’s harder to say no when it’s someone in my host family or the other healthcare professionals I work with… the person who helped me when I was sick, the person who fed me an incredible meal… With the hospitality level so high here, I feel like people are offended when I don’t jump right in to examine them when I’m off-duty. And when it’s one of the nurses I work with saying, “There’s this little boy who can’t walk and his family is simply too poor to pay the 5 soles for therapy...” Where would YOU decide to draw the line?

Exploring Trujillo and Peru Mission

I’d made a few short trips into the “big city” before this past weekend, but they were usually for a quick meal with someone, so I hadn’t really gotten a good feel for Trujillo yet. Saturday I met my friend Jose in town and he gave me a fantastic walking tour, beginning at the Plaza de Armas (picture below). 

Jose works for an organization called “Peru Mission” (www.perumission.org), a facilitator of Christian community development here in Peru. The programs in Trujillo range from group Bible studies, music and medical mission work in clinics to economic development including a microfinance program and a locally-run woodshop.  He gave me a tour of the woodshop and I was completely enthralled by the whole process. They use wood that’s already been cut down for other reasons to create these absolutely incredible looking modern works of art.

 

We also wandered through the large marketplace and shopping area in downtown Trujillo, and Jose helped me get my bearings as many streets look alike here. Trujillo definitely feels a lot more clean, modern, European and safer than La Esperanza, though only 15 minutes away. The big city ambiance is quite the contrast from the outer-lying poor communities- clean paved streets and brightly colored buildings with a mixture of architectural styles, some areas reminisce of the Spanish historical influence in Peru. Trujillo also boasts a lot of modern amenities- hot showers, fancy apartments and restaurants, 2 malls, and even gyms and lap swimming pools! Though we wandered around the “tourist area,” I haven’t seen a single other American here, aside from my friends in Chimbote and Jose.

The highlight of the afternoon, of course, revolved around food. We stopped in at Jose’s favorite place to get a sandwich de pollo- shredded chicken in a bun with sauce and vegetables piled on- fantastic! And then had some dessert – my first taste of Peruvian helado. It had to be the best ice cream I’ve ever had. I’m trying to pace myself with the food for fear of stomach problems but it’s really hard to hold myself back!

A Cultural Tidbit

                                        The neighborhood Catholic Church 
 
Peruana Cosita Importante #5: At a Catholic mass here, you only take communion if you’ve committed a really big sin in the previous week. (Let’s just say I learned this the hard way, and of course my host family got a big kick out of it!!)

Enough said…

5 THINGS TO KEEP ME HUMBLE

Here are five parts of my daily life here that serve as frequent reminders to always strive to be humble:

1) Drinking water
I retract my previous statement about Steri-pens. (Mine stopped working exactly one week after my arrival.) After that, I began drinking boiled tap water, but it was a bit murky and occasionally contained small black worm-like bugs. After that discovery plus a 5-day bout of fevers, vomiting, etc. I’ve succumbed to drinking bottled water. I’m lucky I can afford it- the locals don’t ever drink it.

2) Showers
In the beginning, I prepared myself for the freezing cold shower by doing squats, push-ups, plyometrics, etc. before bolting in and out. My housemates thought I was crazy. However, it’s not hot here yet and the showers still leave me shivering for the rest of the day. So, I’ve given in and now take a bucket shower twice a week, as do the members of my familia. I mix boiled and cold water and use a little plastic cup to dump it over my head!

3) Toilets
A lot of the toilets here don’t have toilet seats, including mine, which makes life interesting. Also, the plumbing systems are such that you dispose of all toilet paper into a bucket next to the toilet instead. But hey, beats the dark night trek to the outhouse in Mexico! :)

4) Garbage
No trash cans here... Just small plastic bags on the countertops that attract bugs. Every day the trash truck comes by, announcing its arrival with a loud clanging bell. People rush outside with their trash from the day before and leave it in the streets. It seems that a lot of it never actually makes it into the truck, as the streets are covered in litter. with accompanying odors, in my neighborhood (less so in Trujillo). (However, random side note, Peruvians take great pride in their sidewalks, and every day they are out there sweeping the dirt aside.)

5) Hand Sanitation
Hand-washing seems optional, and soap even more optional, expensive, and rarely utilized here. I feel like a complete germ-a-phobe carrying around my little hand sanitizer bottle, but it does come in handy, especially at work. With all of the above issues related to sanitation in general, I can’t help but wonder exactly how many of the minor (and major!) health problems here are preventable.

FISIOTERAPIA

The first thing I noticed when I walked into the PT room at the clinic was a skeleton model that had one arm. This one arm was not only on the wrong side of the body, but the scapula protruded from between the 4th and 5th ribs… coming out of the front of the chest cavity! I hoped it was not a bad omen of things to come.

The entire clinic itself is a lot larger than I had expected- over 70 people work there (30 doctors) and it has a 24 hour emergency room. Health professionals from a number of disciplines including gynecology, pediatrics, odontology, trauma, internal medicine, psychology, nutrition and alternative medicine are represented. They’re also are equipped for diagnostic imaging and blood lab work and have a pharmacy on site. It’s a beautiful, clean, facility full of friendly staff!

I was pleasantly surprised to learn upon my arrival that there is actually one PT currently working in the outpatient clinic. However, she is only there 9 hours a week. And, according to the man who is in charge of the Ministry of Health in this area, no full time PT exists in the public sector- serving the poorer individuals- in all of La Esperanza. Nobody!

I learned a lot during my first week of work at the clinic. I am splitting my time between working there, at a school, and on the public health program – “El Proyecto.” Before I get into the details, I just want to say that future commentary on the healthcare system here is by no means meant to incriminate or belittle the practices and culture. Rather, I hope that my observation on cultural differences and their impact on the quality of care will bring light to the challenges that need to be addressed regarding healthcare worldwide.

That being said, I think it’s fair to say that the level of PT here may be compared to the standards of care in the US from many decades ago. Documentation is sparse- one little box in the patient chart listing the day’s treatment, or nothing in the case of a walk-in patient. No evaluation forms, no doctor notes, no daily notes, no insurance paperwork. Definitely no outcome forms, home exercise programs, or even past medical history forms.

Patients here pay the same price regardless of whether they have a doctor referral or not, which is 8-10 soles normally (about $3/visit) or if they see me, only 5 soles since I am a volunteer. $3 sounds great to us, but when you remember that 8 pieces of bread cost 1 sol - 0.33 cents in USD here, it’s not always that affordable. And, if it’s the father of the house who is in for therapy, you’d better believe he is really stressed out – not only is he paying to see me, but he’s out of work due to his injury, and his entire family is depending on him for food. No such thing as worker’s comp here!

Fisioterapistas here go to a technical type of school for 3 years, right after they’ve finished the high school equivalent. There’s one PT program in this area that has about 20 students per year to serve the 1+ million people inhabiting the Trujillo area. Lima has several schools.

Normally I won’t be working at the same time as the other therapist (we have different schedules) but this week she was showing me the ropes, so to speak. The treatment I’ve observed so far includes Infrared, TENS, moist heat, massage, range of motion exercises and PNF’s in supine, and Ultrasound at an intensity of 0.1 w/cm2 (reason = “any higher and the patient may be uncomfortable”). I haven’t observed any initial evaluations yet but was informed that PT’s do not perform special tests; they generally leave the diagnosis for the doctor and stick to modalities for treatment.

Last week I visited one of the two local hospitals in Trujillo and met with some doctors and interns there. One of the doctors informed me that inpatient PT is pretty much unheard of- patients with hip and knee surgeries, for example, receive no post-op rehab and are told by nurses to stay immobile/bedridden for as long as possible after surgery! Yikes… DVT waiting to happen, among other things.

Similar to experiences I’ve had in other countries, I’ve already had a hard time taking this all in. It’s clear that physical therapy in this part of the world lacks evidence-based practice. To confound matters, there is a significant, complete lack of inter-disciplinary communication in outpatient and inpatient care here. I’m planning to incorporate a section of El Proyecto to (delicately, tactfully) attempting to shift the standards with some of these things- whew, good thing I have one year!
If you have any ideas I’d love to hear them, post them here or email me!

MI CASA ES TU CASA

I’ve been overwhelmed by the amazing hospitality here. On day five I made a switch to a new casa a few blocks from my old one, for various reasons, the most important being that I did not have access to the kitchen at all. Now I’m living with (rough estimate) about 15 people, but I’m not entirely sure because I haven’t met everyone yet and a lot of people come and go. It’s an outdoor design similar to the previous house, but has a bigger living space, a little more privacy, and a lot more safety. I am very grateful for the switch as now I can have meals and use a table to study more regularly! Also, the family is incredible. The mother, Nelly, and her two daughters Karito and Betsy, plus various aunts live in my section of the house. Upstairs are aunts and cousins, and through a connecting door are aunts, cousins and occasionally the father (he works in a fishing town so is only home a few time a week). People are always here and there is always something going on. All of the girls (ages range from 6 to 22) are studying English, so we have “clases” together and in return they help me with my Castellano! Mi familia has been nothing but generous and incredibly helpful and I feel so very grateful.

Peruana Cosita Importante Numero 4: The greeting here is a kiss on one cheek. If you show up to a party or gathering, everyone in the room stands up and forms a line to greet you in this manner, even if there are 30 people in the room!

The friendliness of people on the streets has also been improving. Apparently I am the first white person to visit this neighborhood, let alone live here. At first, I felt like everyone- even the perritos (dogs)!- stared at me. This is my first experience in another country completely away from a group, so the stares took a little more getting used to than I expected. It’s been hard to crack smiles or hellos from most of the people I see on the street, but I’m making some progess, slowly. Peruvians seem to hold a lot of stress of daily hardships in their faces, but once you get to know them, everyone is so friendly. I am hoping that now that I am with a huge family, will be attending the local church, and starting work on Monday, people will associate me with something good and maybe the street vibes will improve. My biggest struggle so far is with lack of exercise- I was hoping to walk every day but I am constantly warned by everyone I meet that it is extremely unsafe, even during the day. However, my “sisters” Karito and Betsy have already asked me to teach exercise and yoga “clases” in the casa, so surely I’ll adapt to new methods of exercise this year.

La Comida Peruana

Peruvian food is very rich and interesting, and it also varies according to geographical location. Trujillo is known for it’s seafood and ceviche is very popular here. (Sadly I am allergic so will not get to try it). Also, interestingly, “chifa” – Chinese food – is extremely common here.

My taxi driver in Lima told me that the people of Trujillo and the northern region are “really fat.” My first few days in Peru, Antolino said that “I am too skinny, he needs to get me fat” so he was doing his best to feed me constantly, but all he knows how to cook are eggs, so when we didn’t eat eggs, we had “fast-food” from the street. Street food I’ve tried so far includes fried chicken, french fries and salad. Plus mayonnaise- on EVERYTHING. I mean everything.

Peruana Cosita Importante Numero 3: If you don’t pretend to LOVE mayonnaise and treat it as a special luxury and put it on EVERYTHING you eat, people think you are weird.

In general, Peruvians tend to be a bit overweight, and I have yet to see the stark signs of starvation that I noticed in Africa. But, it’s also not nearly close to the level of obesity in America. The street food is generally unhealthy here but is cheap, so similar to the concept of McDonalds in the US, people seem to make choices based on necessity and financial strains that seem to be affecting their health.

My neighborhood has outdoor mercados everywhere. The mercados are fun to explore- they sell everything from brightly colored fruits and vegetables to bins of rice and spices, freshly squeezed juice, sugar cane and fresh coconut, “quick food” stops – tables set up outside around lunchtime, shoes, toys, and car parts. Many people also have small shops in their homes – bodegas - where you can find soda, crackers, candy, phone cards, etc. I’ve found one place that – to my relief – sells pasta! So, when I need a gastrointestinal break, I know where to go.

I’ve been to one supermarket but it’s about an hours commute one way with the public transit from where I am living. I felt like a little kid in a candy store- amazed at all of the familiarity I found (they have soy milk and cereal.. what?!!) But there were also some of my previous staples missing (yup, no mac ‘n cheese). While I enjoyed the options of the large chain, in general I will stick to supporting my neighborhood options. I definitely want to experience as many local foods as possible, and I’ve already purchased a Peruvian cookbook! Plus I enjoy interacting with my community here in La Esperanza in the markets. People here buy a little at a time and seem to utilize the market daily. One stand for bread, another stop for eggs, another for fruit... it’s so simple!
Some of the Peruvian food I’ve tried with the hermanas (nuns) include ensalata mista (beets/potatoes/carrots), chicken, various soups, maize, salad, and tamales. Rice is a staple of the diet here. Also, chicken legs in soup are a delicacy, as I discovered, much to my dismay on my first day! But I will need to braver, as there’s another delicacy here called cuy – guinea pig!

The postres (desserts) are by far my favorite part so far. I’ve tried picarones, which are donut-like fried dough pieces made of pumpkin and topped with a cinnamon syrup. The pastries sold on the street are also delicious. The most popular gaseosa (soda) here is called Inca Cola – kind of a cross between Mountain Dew and Bubble Gum! Very sickly sweet yet strangely addicting- I finished the bottle despite the instant stomach pains it brought on!

Initial Impressions

I’ve likened my first impression of my neighborhood to a cross between Mexico and Ethiopia- I know, sounds strange! Everyone here seems to have a cell phone and TV, no matter what their financial situation. The visible poverty seems less than Ethiopia at first glance- less beggars in the streets. The buildings and markets remind me more of Mexico, and Catholicism is most common here, like Mexico. The little mototaxis remind me of what we saw in Africa everywhere. No donkeys pulling carts in the big city here, but lots and lots of homeless dogs, like both places. My neighborhood is notorious for its crime but so far I have not been harassed or felt threatened, but I am cautious and do not venture out alone at night. The brown dirt that lines the streets somehow finds its way into everything, and the road conditions in La Esperanza are poor- watch your step all the time! The homes are unfinished on top, like the ones I saw in Mexico. (In Mexico it was so that you didn’t have to pay taxes on them- maybe the same reasoning here?) A lot of brick and cement exteriors on the houses, and barred doors/windows. The traffic is loud, always sirens and horns blaring. I am about one block from the main road and 5 blocks from the clinic/church. The driving is probably the scariest part, I still hold my breath when I get into a taxi, as I did in Ethiopia, but I suppose I will adjust to the crazy drivers and lack of seatbelts.

The housing situation took some getting used to, but now it feels more like home. It’s an outdoor design – only the bedrooms and kitchen are completely enclosed. I feel very fortunate to have plumbing and electricity! Frigid showers (no exageration) and no bathroom mirror, which means minimal getting ready time for me in the morning! No heating which is not a problem now but could get pretty cold come winter, especially with the holes in my door. There are cucharachas- my least favorite bug- and the little girl in the room next to mine screams for several minutes every time she sees one (and I almost do the same!) My room consists of a short twin bed and a small bedside table, a see-through curtain, and cold dirty floors- no desk, chair, closet. It’s funny the amenities you are so used to in the US– but really, after a few days, I’ve realized that I don’t need them! There are a few things that I still miss, including toilet paper- a rarity here.

Peruana Cosita Importante Numero 2: Glad I packed… slippers (thanks Cathleen!), long underwear, a small mirror (so I don’t develop a uni-brow), a reading light, my yoga mat, and my Steri-pen.

*If you don’t have a Steri-Pen and are an international traveler I highly recommend it! It saves the environment- No need to buy bottled water as the little UV light supposedly kills all the bad stuff. The water tastes a bit funky but so far, no stomach problems!

They say that similar to mourning, you go through different phases when moving to a new country by yourself. The first is a few days period of excitement and awe, followed by a longer period of depression, possibly several weeks, before you adjust. Maybe because I’ve been fortunate to travel a lot before this, my “depression” phase lasted about 5 hours, and now I feel pretty adjusted. I’m so grateful for the hospitality of my host dad and the friendship of Hermana Sandra (she is hilarious!) and the other nuns and hospital staff, who have helped tremendously. They’ve made my transition very smooth and I already feel pretty comfortable in this new culture!

One Long Journey!

First of all, I stand corrected… I had 5 flights, not 4, in over 40 hours to get here… next time I will look at my ticket more closely! Fortunately I only had to lug around the 240 lbs. of baggage and carry-ons during 2 of the 4 stops. It was an exhausting journey, but during my 12 hour layover in Lima I had a chance to get some sleep so I was pretty pumped and energetic by the time I got to Trujillo. It was interesting to see the vibe of the people change over that time… each flight had less and less familiarities (language and otherwise) in the people around me. I already have a few friends in this new place including a cab driver in Lima who informed me “that I will marry a Peruvian before the year is over.” Ha.

I got to practice my Spanish on my last few flights, and also during my 8 hour layover in Mexico City, which improved my confidence. I had a window seat flying into Trujillo and it was awesome to emerge from the clouds and see this brown, barren-looking but very beautiful landscape of mountains and cliffs on the seaside. I’ve never seen anything distinctly like it. After collecting the bags once more, I was promptly greeted by this adorable, energetic nun and her brother, Luis. Everything moved quickly from there- we were shuttled into a tiny car and I learned my first “Cosita Importante” about my new life:

Peruana Cosita Importante Numero 1: Always hold tightly onto something in a moving vehicle, even if you are buckled, or you will get a giant bump on your head. Ouch.

When we arrived at my new casa, it was already dark and we literally threw all the bags at mach-10 pace through the door before congregating inside for introductions. (Apparently not good to stand outside at night in my neighborhood.) My host family consists of mi padre, Antolino, madre Maria and bebe Isabel. However, mom and baby were on vacation so it was me and Antolino to start. He is a traveling salesman from Trujillo. He is also hilarious and talks really fast. I was amazed at how much Spanish I could understand from the nuns at the beginning. However, with my new padre there was a lot of nodding and “Si’s” to who knows what those first few days! He is very talkative and sweet and I’ve already seen every photo in the casa, his extensive collection of antique Peruvian coins and bills, and his DVD collection of Peruvian music/dancing. He gets up before dawn is on the streets all day selling his goods, and sometimes travels to other regions for sales too. He is a hard worker- says he is barely scraping by, which seems evident from his simple lifestyle and sole pair of shoes which are literally falling apart into pieces. He has a huge heart and I’ve already learned a lot about the culture from him.