Buenos Dias Bolivia

It’s strange to think that two years have passed since Jane and I started having conversations about me going on an international rotation. More than that if you consider the fact that I was applying to PA schools three to four years ago and picking out those that boasted well-established international rotations. And now it’s done. The hospital, the apartment, Luz de Mar (the go-to spot for lunch), the rickety boat ride across the river, the obnoxious late-night karaoke, the hike to the cross… they’re memories now.

The only two ways out of Rurrenabaque are to either take a thirty minute, twenty-passenger plane to La Paz or take a sixteen-hour bus ride through the mountains across roads so narrow and close to the edge that you won’t find a local that would recommend it. Even though we spent the better half of the day before we left fighting with the airline, it was worth it to avoid the latter. It meant, however, that we had an eighteen hour lay-over in La Paz. After exploring the city, it quickly became obvious that we made the right choice.

La Paz sits at over 12,000 feet elevation, nestled in a valley within the Andes mountains. The location was originally chosen for its strategic location between Lima, Peru and trade to the east. Today, however, it’s marveled more for its unique 360-degree mountain view. Their public transportation consists of a very confusing and overwhelming bus system (that got Nikki and I lost for thirty minutes before finally finding Nicole) and the Teleférico. The Teleférico, an aerial cable car system that looks like a ski left, functions much like subways do in major cities across the world. This system, however, not only surely saved the city loads of money in construction and operations, but additionally offers its users breath-taking views of the city and the surrounding mountains.

Touring La Paz was a great way to cap off the rotation, and an experience that deserves more than an eighteen-hour lay-over.

A week prior to leaving, we got together with an American couple we met in Rurrenabaque for a thanksgiving meal. Steve and Lisa are spending a year in Rurrenabaque working with an engineering company that provides water restoration for small, rural communities. During our meal (which despite the fact that our turkey was actually a chicken, turned out pretty true to a classic Thanksgiving dinner), we took turns sharing what we were thankful for. Everyone had things unique to them, but some resounding themes stuck out.

We were thankful to be eating American food, that we weren’t sleeping in tents that night, and that we had a thanksgiving pie to look forward to after the meal. We were thankful that none of us had (yet) acquired Dengue Fever. We were thankful that we were provided an education and given the opportunity to travel overseas for a rotation. We were thankful for prospective; that we could see how other cultures practiced healthcare, how the people of Bolivia care deeply for one another, and that they seem to do well without the distractions of American technology and luxuries. We were thankful for the hospitality of the people of Bolivia and of their genuine interest in us. We were thankful for the vision that it has given each of us, and the yearning to return to Bolivia or elsewhere to provide healthcare to medically underserved people groups. We were truly thankful for the experience and forever grateful to the people of Rurrenabaque, Bolivia.

¡Gracias por leer!

Cameron

The four of us students asked each other a few days ago what our favorite and least favorite parts of the rotation have been. My answers were both during the community trip. I can distinctly remember the emotions I felt while lying in agony in my tent that had been baking in the sun all day, coated in a layer of sweat that in part was due to the 95% humidity, hoping it wouldn’t rain and soak the floor of my tarp-less tent. The only escape from the intense heat that night was to go outside into the slightly cooler night air, only to be greeted by a swarm of hungry mosquitos. Then again, I’ve never felt more called to a profession than when I’m seeing patients who live hundreds of miles from decent health care. The satisfaction I get from knowing people five hours down the river are being pursued medically is what fuels me to be a better and more intentional provider.

Our crew was comprised of the four PA students, and a team from La Paz consisting of a physician, a dentist, an intern, three nurses, a cook and her husband, a guide, and Antonio. We set out in a tiny boat with medical supplies, our camping gear, and enough food for three days.

After we had already traveled four hours, but before arriving at our final destination, we made a stop at an even smaller community to see anyone who needed medical attention, and provide vaccinations to the children. At first, however, it kind of felt like we were just there to take the fruit from their trees…

After seeing a handful of people and batting/catching mangos from the trees, we hopped back on the boat for the hour-long ride down to our community. It had just rained, so we were glad that our journey continued downstream.

We spent the rest of the afternoon becoming acclimated to our new home. From the laughing that came from close-encounters with wild pigs and the fun we had setting up tents to the realization that there weren’t functional bathrooms or fans in the school-house, things definitely felt different than they did back in Rurre.

We capped off the night with an incredible dinner. We were spoiled to have such amazing cooks with us.

Day two was all about the town, and the people that were eager to see us. Our school-turned-clinic was the perfect size to accommodate the 17-family village. Our set-up comprised of a triage, two medical stations, a section for our dentist, and a pharmacy. By 8:30, the members of the town started heading our way (notified via a piece of metal banged on the metal door frame).

As the patients flooded in, we divided ourselves up amongst the native Spanish-speakers and got to work. A lot of patients had chronic back pain from working on their feet for 40 years. Some of the kids had bacterial infections that required antibiotics. Nicole even got to pull a tooth while she worked with the dentist.

For some reason in this country, someone always has a monkey they just found in the jungle…

The following day we packed up and headed home, but not before stopping at one more small community on the way. There weren’t many patients to see, but there was a parrot. He stole most of my attention…

And as soon as it began it was over. It was a whirlwind of excitement, joy, heat, medicine, mosquitos, and pride in our work.

We were so fortunate to go on a trip like this. It is an experience that can alter one’s view of health care and impassion them to pursue the medically underserved. The experience has further shaped what I foresee my future to hold. I eagerly expect that it will do the same for others that are fortunate enough to experience and/or provide health care in medically underserved areas of the world.

Alas, the trip is nearing an end. I’ll share my overall thoughts of the international rotation in the next blog.

Hasta la próxima,

Cameron

When one has studied medicine in the United States, it doesn’t take much exposure of another culture to realize that people across the world approach the subject differently. For us, sometimes that difference is subtle and sometimes it’s shocking. Every culture must make the most of what they have, approach their patients based on established cultural norms, and prioritize things in their differential diagnoses that are common to the area. These things provide a very different view of health care to someone of a different culture.

Each day begins at 7:30am at the hospital in San Buenaventura, which is a small town across the river from Rurrenabaque. So at 7:00am we pack up with our scrubs, stethoscopes, and rain coats on and head towards the Rio Beni to catch the boat ride across. The trip costs 1.50 Bolivianos, the equivalent of $0.22 USD, which in our opinion is well worth it for the view. In fact, I sometimes think that the boat drivers deserve more, especially after one day when the current was so strong that we had to go directly up stream and drift to the other side all while dodging a minefield-like river surface of branches and debris. The applause we gave him didn’t quite seem like enough.

The hospital which, except for a few small outpatient clinics, services the people of San Buenaventura, Rurrenabaque, and many surrounding villages and communities. Despite that, the hospital reaches max capacity of inpatients at six. Additionally, there is a small emergency department that, along with a few other offices, is more like an Urgent Care by US standards. The hospital also has an OBGYN office, an operating room, and a small lab, as well as an ultrasound and an electrocardiogram. The hospital is very small with minimal resources; much different than most hospitals in the US. By American standards, one could easily criticize the muddy floors and paint-chipped walls, or find the old, broken down chicken coups in the courtyard disconcerting; or scoff at the lack of sterilization or patient privacy. Yet by approaching the rotation with arrogance one could easily miss the colorful mango trees in the courtyard or the breathtaking view of the river from the entrance; or not notice the benefits of communal health care where members of the community take it upon themselves to help those around them that are sick. If one opens their eyes, they will see a beautiful and efficient hospital that cares deeply for its patients.

Nikki and I have been working with Dr. Octavio in the Emergency Department. One of the major differences we’ve noticed, as it would be with any health care system other than one’s own, is that a differential diagnosis must include things that are common to that area. For example, in Bolivia, it is important that before diagnosing someone with a viral cold to consider mosquito-borne illnesses such as Dengue, Malaria, Zika, and Chikungunya. These sometimes-severe illnesses can present with non-descript symptoms that mimic that of a cold. Fever, headache, abdominal pain, fatigue, and weakness are often the presenting symptoms. Such mosquito-borne illnesses are seldom considered in the US but are a part of everyday medicine in Bolivia.

One of my favorite topics of medicine is something I call “minimalistic medicine,” which is essentially practicing medicine to the best of one’s abilities with less-than-ideal resources. Again, by US standards, sometimes medical equipment and laboratory testing in Rurrenabaque, Bolivia is less than ideal. As such, one thing that Dr. Octavio has taught us is a greater appreciation for history and physical exam skills.

To extrapolate on this, we discussed what to do if someone comes to the clinic with signs and symptoms of a stroke. Regardless of the region in the world, it is crucial to differentiate a hemorrhagic stroke which is caused by bleeding in or around the brain from an ischemic stroke which is caused by a lack of blood flow to the brain. Coming to a correct etiology is important, as these somewhat opposite causes of a potentially fatal condition are initially treated with two different medications, and if given the wrong one, could prove to be fatal. Therefore, in the US, a patient is immediately sent for a CT scan for diagnosis. In Rurrenabaque, Bolivia however, the closest CT scan is in La Paz, which is over sixteen hours by car or several hours by plane. This also assumes, of course, that someone can transport them, the airport is willing and able to fly them, and that someone would have the means necessary to stabilize them on the way; such luxuries are mostly foreign to this region of the country. In talking to Dr. Octavio, we learned how to catch subtleties in a patient’s history and physical exam that help clue one in to the correct diagnosis and treat accordingly. In this part of the country, minimalistic medicine forces you to have a heightened sense of awareness to a patient’s clinical presentation.

It is such a remarkable thing to get to experience how health care is done in another country. I couldn’t speak more highly of the experience and would recommend anyone to go if they have the opportunity. The doctors thus far have been helpful, accommodating, and encouraging. Even though the language barrier exists, Dr. Octavio and the other health care providers in the hospital have gone to great lengths to make sure that we understand them and our patient interactions. Luckily, medical Spanish consists of many cognates. In fact, that, along with context and words that we have studied or already know, has made communication easier than I originally would have expected.

As soon as we were growing accustomed to what we had in the clinic, we were forced to rely on even less when we packed up and went on a community trip five hours down the river with nothing more than a few back packs, a bag full of tents, and a couple bins of medicine to provide health care to a small, rural village. Probably best to save that trip for the next post.

¡Salud!

Cameron

After roughly ten days in Bolivia, it’s finally starting to feel a little more like home. And how can it not when you spend your afternoons lounging in hammocks on a palace-like balcony with mountains in the background? Apparently, we are the first students to stay at this specific house in Rurrenabaque and it does not disappoint.

Rurrenabaque, Bolivia is a little town that borders the Andes mountains at the exit of a tributary that eventually feeds into the Amazon river. As such, this long and narrow town sits snuggly between an incredible view of the Andes Mountains to the west and the Rio Beni tributary to the east. To put it into perspective, these two pictures were taken from our balcony of the Andes and Rio Beni respectively (the Rio Beni is hard to see in the picture, but it’s at the end of that road). Even without some of the American comforts we’re accustomed to, it’s hard not to feel like this is paradise.

The culture of this town is unlike most other cultures I’ve experienced. The people are friendly, eager to say hello, curious as to why you’re here, and quick to offer advice about their town and country. Our team, shown to the left in order from left to right, consists of Tanaya, Nikki, Nicole, and myself.

It’s summer right now, here in the southern hemisphere. As such, our biggest challenge has been the intense heat and humidity/rain. The nights are often long as a result, especially when combined with the city that truly never sleeps (late night karaoke on weeknights has gotten old, fast). The rain jacket and backpack cover I bought before coming have been crucial in keeping me sane during the day, and the fan provided to us upon arrival has been crucial in keeping me sane during the night. That being said, the discomforts are easy to overlook when we remember that we’re doing a clinical rotation in the Amazon Rainforest. Not many people can say they’ve had such an experience. More so, the experience has convicted us that people live in uncomfortable environments all over the world, many in worse conditions than this. It’s a reminder to not only not take our American comforts for granted, but also that there are many others across the globe without access healthcare and basic necessities. It’s certainly reaffirmed for me the desire to provide healthcare to medically underserved people groups.

Life here moves much slower than it does in the United States. As such, these always-busy Americans have made the most of our down time. We’ve gone on several hikes that have offered incredible views of the town. On one such hike, we climbed one of the more challenging trails in the area to the top of a mountain. We noticed a cross from our balcony early last week and decided to go find it.

The climb was steep and challenging. It began with several hundred tall and narrow stairs and continued on with a trail that forced you to brace yourself on tree branches below while grabbing onto roots above. The pictures don’t do it justice, but it was a tough climb. However, the view from the top was worth it.

The hike we went on the next day was less intense but still nerve-wracking as the trail was narrow with steep drop-offs. Yet again, it produced some great pictures. The trail went along the town’s pipeline, their main source of water.

On Sunday, Antonio took us fishing on the Rio Beni. To clarify how cool that really is, a family member of mine said that he once considered going on a fishing trip to the Amazon, but it would’ve cost him something like $3,000. And here we are, going out on a little boat made by 2x4s with a Bolivian man that wants to show off his country and make sure we have a good time. All for free.

All in all, this past week has been beyond what we could have expected. There is a lot to learn from the people of Rurrenabaque, Bolivia. And that includes their healthcare and how medicine is done here compared to in the U.S. That will be the highlight of next week. Until then, ¡Hasta Luego!

Cameron

“¡Hola Antonio! Esta es Cameron, un estudiante de Dettmann (perdóname, mi español está muy malo)… nuestra (Nikki y yo) avión llega a 1005. ¿Te veo mañana?”

This was my first attempt at Spanish for the trip, and a text that I’ve been nervous about for months now. Respectable sure, except for the fact that it took me over five minutes to write. Shortly after sending that text to our preceptor in Bolivia, Nikki and I boarded a plane to continue what would ultimately be a 32-hour trip to Rurrenabaque, Bolivia for a rotation during our clinical year of Physician Assistant school. And it was there in the terminal, during our first layover in Orlando, Florida, that things started to slowly become different. Over half of our flight was comprised of families visiting Disney World who were returning to South America, and as such, the announcements were split into Spanish and English. The language barrier has thus far been one of my biggest anxieties when preparing for the international rotation. Our next layover in Lima, Peru was a little further from comfortable, but you could at least hear English occasionally, and certainly most flight attendants and airport staff were bilingual. Then came the last layover in La Paz, Bolivia, where we truly felt removed from home. Nikki and I found ourselves needing to resolve an issue with our customs forms and you could almost see the hope dwindle from each of our faces as we collectively realized that none of us could effectively translate. Even now, as I sit in the airport, I’m overwhelmed with frustrations at myself and how I wish I would’ve paid a little more attention in Spanish class, or taken a few Spanish classes in college, or even studied abroad. Yet we’ve so far effectively stumbled our way through every conversation. And furthermore, I’m becoming more and more confident that this was a good decision. As the plane flies over South American cities and we make our way in and out of difficult language barriers, my anxieties are being wiped away and replaced with memories.

I knew before starting Physician Assistant school that I wanted to attend a school that offered international rotations. In fact, it was one of my highest priorities when looking for PA schools. MCPHS was the first that jumped off the page for me. The mission statement I’ve created for myself – my life-goal – is to provide medical care to medically underserved people groups. This was originally birthed out of a medical mission trip to Cambodia, where I met with patients who had never seen a healthcare provider before. Furthermore, it was this trip to Cambodia that solidified the desire to become a Physician Assistant. Becoming a PA and working in healthcare is great, but helping people get medical attention that don’t readily have access to it is what has driven me through school. I eventually want to teach as a professor in a PA program (alongside practicing), and advocate for international rotations. I’d thoroughly enjoy providing healthcare to one person who doesn’t have access to it, but it’d be even better to inspire more students to do the same.

To the right is a picture of my awesome wife and I. I honestly had many thoughts early on in clinical year about canceling my trip to Bolivia because of the distance we’d face. We’ve never been apart this long before and saying goodbye for the month was very difficult. Yet we are both confident that me going to Bolivia is the right choice. Many, maybe just several, years from now, I’ll be convincing students to go on a clinical rotation who could be in a similar situation. Everyone has things they’re leaving behind: relationships, American food, Sunday football (I’m actually hopeful I’ll be able to screen games… fingers crossed!) But providing access to medically underserved people-groups sometimes comes with that sacrifice.

To-be-determined are the inevitable illnesses we’re bound to acquire while down in Bolivia. I’m hopeful that they won’t completely debilitate us, but Nikki is currently laying on the floor next to me in the airport. Who would’ve ever thought altitude sickness was that bad!? (definitely not Nikki and I…). La Paz, the airport we’re currently in, has an altitude of nearly 13,000 feet, which is roughly 13,000 feet more than what we’re used to. Luckily, Rurrenabaque is at a much lower elevation. We should’ve planned for this long of a layover, but oh well… hindsight is 20/20. Pro tip: if you find yourself in a similar predicament, your go-to cocktail should be lots of water, Ibuprofen, and oxygen (you can get oxygen from most pharmacies). And walk slowly! (our first mistake).

I think even though we’re exhausted from travel, nauseous, and frustrated, Nikki and I (and most likely the other two students who are also going to Bolivia but are flying separate), are just excited to get started with the rotation. This rotation, and other international rotations, are built on the foundations of students that’ve gone in the past. We’re thankful that that makes our lives easier, but we’re also hopeful that we can make an impact on the community here and inspire and encourage other students to continue building relationships with the people of Rurrenabaque, Bolivia.