Done with the rotation!

Today was the last day of my research rotation (I'm still in Peru; not leaving until early Sunday morning, but all I have left to do is hang out in Lima and spend money I don't have at the Inka Market). It was a pretty low-key day; all I did was give my presentation. Here's the title slide:

Both LCDR Maves and Wes (the Georgetown student) chuckled at the little bugs at the bottom. So, in case you can't tell from the title, I focused my research and my presentation on entomology (the study of bugs, not the study of language--that etymology) and its role in preventive medicine, starting with the history of diseases carried by bugs in the military, with a healthy amount of information about MAJ Walter Reed, because no self-respecting Army preventive medicine resident can do a project that has anything to do with bugs without talking about MAJ Walter Reed.

So that was that. As I was filling out my evaluations and preparing to email the presentation to my program director, though, I realized I never turned in a research proposal to her (supposed to be done one week before the research rotation begins) because I never filled one out. So I did that this afternoon, too, and amazingly enough, I did everything from my proposal during this rotation. I'm just that good (filling things out retrospectively doesn't hurt, though...).

Now I just need to figure out what I'm going to do tomorrow that won't end up costing me another few hundred Soles... (BTW, Mom, I found a painting I think you'll really like. Happy birthday. You'll get it a week after our birthday, when you and Dad come visit).

Neurologic Institute

Sorry about the delay in posts... my computer wasn't reading my SD card, so I couldn't get images from my camera to the computer, and I didn't want a bunch of posts with "and I'll get you the pictures later" all over them.

On Monday, we took a field trip to Instituto de Enfermedades Neurologicas, which is a neurology hospital where they do a lot of treatment and research on cysticercosis, a parasite (worm) infection that can travel to the brain. Most people, surprisingly enough, can have hundreds of cysts and not have any symptoms worse than headaches, which is how they remain undiagnosed long enough for them to have hundreds of cysts.

On site, they also have a museum of brains, with a few walls of specimens of brains with various diseases:

And here's a close-up of a brain with neurocysticercosis:

They also had some healthy specimens, including this one of the central nervous system:

So that was Monday. On Tuesday, we went to Instituto Alexander von Humboldt, which is a tropical medicine hospital. In the morning, we sat in on Leishmaniasis clinic (parasitic infection that causes open ulcers on the skin--got a lot of press in the early days of Iraq, when troops were being MEDEVACed with Leish after getting bitten by sandflies while they slept in the dirt), and then we rounded with one of the attending physicians, who showed us some very interesting cases, including a woman who complained of facial swelling, pain, and "worms coming from her nose". They thought she was crazy, then they actually saw maggots coming from her nose. A fly had flown up her nose and laid eggs, leading to an infection called myiasis (yes, maggots coming from the skin actually has a name). Disgusting.

Then yesterday was spent working on my presentation on Bugs of Military Significance, which is what I'll also do today. Apparently, people want to see something come out of this rotation... apparently, they aren't sending me to Peru just to sight-see for three weeks. Who knew?

Bus tour of Lima

Yesterday, a couple of us (Wes, the Georgetown med student; the vet tech; and myself) decided to do the touristy thing and took a double-decker bus tour of Lima. The tour started at Parque Kennedy, and before you ask, yes, it is that Kennedy. There's even a bust of him in Parque Kennedy.

Apparently, Miraflores is the sister city of Pensacola, FL. Why that means they need a bust of JFK, I have no idea, but there it is. There's also a statue of John Lennon in another part of town, so I think the Peruvians just like statues.

Anyway, driving around Lima, in Lima traffic, on the top of a double decker bus is a bit of a harrowing experience. This is definitely not the worst traffic was, but I want you to take note of the open manhole.

Although Lima is, overall, a pretty dirty city, they do have some nice architecture and whatnot. Here's a picture of what I think would roughly translate to the capitol building.

And this is the monastery San Francisco (as in, for St. Francis, not the city in California), which I think they were saying is the oldest Franciscan monastery in the Western Hemisphere. The catacombs are also located here, and for about two centuries, (1500's-1700's) they buried quite a few people here. When the catacombs were excavated, they found the remains of over 25,000 bodies.

And here's a random shot of a hill that somebody decided to paint a Peru flag on.

So that, and more shopping at the Indian Market, was my day yesterday, and today, I spent a good deal of my time at the hotel (by the pool, for a good bit), working on my presentation, which I'll be giving on Friday. I'm doing it on the roll of entomology (study of bugs) in preventive medicine, briefly discussing the history of vector-borne diseases on military populations (with a few slides dedicated to MAJ Walter Reed), the Army regulations on insect control, ongoing research projects at NMRCD-Peru, the role of bugs in the deployed setting (malaria, Leishmaniasis, and also the sleep deprivation/psychological impact of being surrounded by bugs and giant spiders... Jason, if you have any thoughts on the matter, I'd love to hear them), and directions for future research. In all, it's supposed to be a 30-45 minute talk, so we'll see how that comes along.

Hospital Dos de Mayo

On Wednesday, one of the doctors took me and a fourth year Georgetown student who's down here as well (Navy HPSP) to Hospital Dos de Mayo (second of May; one of the major battles against the Spanish back in the day), which is one of the public hospitals in Lima and a major teaching hospital for medical students and residents.

The main thing we did there was listen to morning report (well, listen to that doctor translating morning report for us), which was about a few cases of HIV patients. They have a lot of the same problems with HIV patients that we have in the States--mostly, people not being compliant with their medications, and thus getting complications--but they don't quite have the same lab capabilities or treatment modalities that most hospitals in the States have. It was interesting to hear about how some of their treatment guidelines differ because of this.

One interesting thing about the hospital and associated clinics is that they pay for lab tests at a window (as opposed to getting a bill in the mail later). So they have this large sign that has all the prices listed for various labs and tests. I know you can't see it well here, but all the prices are fairly nominal, at least compared to our prices. For example, an EKG costs S/15, which is about five dollars; an echocardiogram is S/60, which is about $20. There's no way you could get an echo for $20 back home. I don't think the few minutes it takes the cardiologist to watch it and declare it normal would even be that little, not to mention the technician's time or the actual procedure costs.

On the grounds is also the crypt of Daniel Carrion, a national hero in Peru, especially in medical circles. When he was a medical student, he proved that systemic (throughout the body) and cutaneous (on the skin) Brucellosis were caused by the same bacteria, by injecting himself with pus from a patient's cutaneous Brucellosis sore. Unfortunately, he died of his little experiment, which just proves one of my points--if you suspect something is going to kill you, don't do it.

So that was my morning on Wednesday. Then I spent the afternoon hearing about research in parasitology (mostly malaria) and virology (mostly dengue) going on in Peru, and yesterday spent the day in the virology lab, learning the various techniques and tests that they do.

Pre-Incan ruins, and back to work

Yesterday I went to Huaca Pucllana, which is a temple built to the water and sun gods of the Lima culture, a pre-Incan culture of around 800 AD. In fact, before the temple was excavated in the 1980's, nobody had any idea that this culture existed. When the Spanish conquered the Incans, they obviously learned about the Incans, as well as the peoples that the Incans had previously conquered, but before that, there weren't really any records. Anyway, before excavation, this was just a dirt hill in Lima (there were houses and whatnot built over parts of it as well. Here's what it looks like today (with some excavation still in progress):

I like this next picture, because it's a good visualization of these very old ruins amidst a fairly modern city. It's actually right in the middle of Miraflores (the district in Lima where my hotel is), and was walking distance from the hotel.

Here's a picture of a fairly famous dog in Peru. Not a famous breed of dog, but a famous dog. Apparently, the Obama's search for a hypoallergenic dog was worldwide news (I'm rolling my eyes), and the government of Peru offered this dog to the Obamas (it's about a year old now, so it was just a puppy then), because as hairless dogs, they're completely hypoallergenic. Obviously, the Obamas picked a different dog, and this one (it has a name, I just don't remember it), is still in Peru, hanging out at some ancient ruins.

And what blog from Peru would be complete without alpacas?

So that was my day yesterday. Today, I had to go back to work (I know, it's not just a free vacation courtesy of the government). I went to the naval hospital for ID rounds in the morning, which was fairly quick--they have three patients, all of which are simple enough that they would have been outpatients back home. Then over to the cafeteria to have lunch with the officers at NMRCD (while making fun of the vast number of uniforms the Navy has... there's an Army vet and an Air Force microbiologist at the lab as well, so we got to gang up on the Navy officers), and then a quick lecture from LCDR (Lt. Commander) Maves, the ID physician whom I'm essentially working under for this rotation, and then back to the hotel to hit the gym and do some homework (which is still sitting in my backpack, waiting for me).

Boat rides and malaria slides

Well, I figured now was as good of time as any to give you some pictures. This first one is the lab where I've been "working" for the last couple of days, NMRCD-Peru, Iquitos Laboratory.

And here's the picture of catching mosquitoes that I promised you yesterday. It's essentially a low-powered vacuum that sucks up mosquitoes and captures them live in a little cup, to be taken back to the lab to be counted and later processed.

Okay. So now what I did yesterday. The day started with arriving at the lab for what I thought was a lecture about malaria in the Iquitos area. What ended up happening was a boat ride to Padre Cocha, a village up a river that feeds into the Amazon. And no, nobody speaks English in Padre Cocha, including the microbiologists who study the blood smears to diagnose malaria. I did learn, mostly through pictures and hand gestures and whatnot (actually, a lot of science-type words are the same in any language), how to tell the difference between the different forms of malaria (P. falciprum and P.vivax) on a blood smear, and the research projects that they're doing on length of treatment for each of those infections. Of the two blood smears we had to look at for that day, one was positive for vivax, and the other was negative for any form of malaria.

Before leaving Padre Cocha to head back into Iquitos, we stopped by a butterfly farm/animal rescue, which is run by an Austrian woman who speaks no fewer than four languages (she was giving the tour simultaneously in Spanish, English, French, and German). They have there a boa constrictor, a few parrots (or similar large, brightly-colored bird), a couple of crocodiles that found their way in, a river manatee, a few monkeys, and a jaguar. The jaguar apparently costs about 1000 soles a week (about $350) to feed, because they only eat raw meat. Although the primary mission of this animal rescue is to return animals to health and find a place to release them into the wild, that isn't possible with this one, because it has completely lost its fear of people (and releasing a large cat that eats raw meat and isn't afraid of people into the wild is bound to result in a few people being eaten). So they keep it, which is rather expensive, and the reason why they didn't want to take any felines in the first place.

So, that was the morning yesterday. Then, after lunch, I went with some of the lab employees (and an entomology grad student from UC-Davis who essentially served as my translator) to see a patient with dengue. Very interesting, but didn't look like much fun. I've been staring at my mosquito bites ever since, hoping that none of them were carrying dengue. Guess we'll find out in 4-10 days...

Counting mosquitoes

Yesterday was my first day of doing 'work' in Iquitos, and let me tell you, doing work in a city where English speakers are very few and far between is not easy.

I started the day by going to IVITA (and no, I have no idea what that stands for, and it's probably in Spanish anyway), where they have mosquito experiment huts. These are similar (and yet different) from the huts that Walter Reed and the rest of the yellow fever commission used way back in the day to demonstrate that yellow fever was transmitted by mosquitoes: you have a sealed hut (sealed with mosquito net, not completely sealed from the elements; I think you'd suffocate) and people and mosquitoes inside. In the yellow fever commission days, they'd leave the people exposed to the mosquitoes and see what happens. In these huts, the person is under mosquito netting most of the time and is just there to observe the mosquitoes. The five huts all have different experiments, but the one I saw had different panels of cloth hanging on the walls, soaked with different concentrations of permithrin, an insect-repellent for cloth and clothing (not for skin). The mosquitoes are counted every hour to see how many land on the various panels, in efforts of determining the concentration that should be used in real life.

Anyway, after IVITA, they took me to the cemetery, where a group of entomologists (people who study bugs) were catching mosquitoes. No, this does not entail running around with a jar trying to catch them--they have these little vacuum mosquito-sucker things with enough vacuum to collect the mosquitoes, without destroying them. Since most people are 'buried' in crypts, they just run these vacuum things over the crypts and collect what they collect. I have a picture on my camera; I'll try to get it up soon.

After that was lunch, which was chicken noodle soup and a pasta with a pesto-like sauce and chicken (really good, but rather heavy for such a hot and humid day), and then it was back to the lab to count the mosquitoes that were collected. The joke about prev med docs, especially the ones who specialize in tropical medicine (like I will someday), is that we go to exotic locations and count mosquitoes--and that's exactly what I did. I learned how to differentiate between the three species of mosquitoes around here and tell the difference between the males and females, because only the females bite, and only Aedes aegypti carries dengue in these parts (malaria is carried by Anopheles mosquitoes, which are found in rural areas, not cities).

And that was the end of my work day, at which point I did my homework of occupational health questions (today I get to have blood drawn... fun, fun!), took a nap, and went out for fast-food chicken with plantain chips to eat while watching TV (something that the other American researchers here do every week). And then I went to bed, went running this morning at a soccer stadium, and am now ready for another day of work.

Writing from Iquitos

Well, I made it to Iquitos last night, after a long day in Lima, and will be heading out into the field in ten or so minutes, so this'll be quick.

Yesterday was a lot of in-processing type activities and in-briefing type activities, where they make sure everything is squared away with my itinerary and teaching me about the various labs. And asking multiple times if I speak Spanish, because apparently, no one outside of people who work for NMRCD seem to know English.

I did get a chance to go over to the medical school in Lima for a lecture the commander of NMRCD (a Navy commander) was giving on viral gastroenteritis for the Gorgas tropical medicine course, which is an international course for doctors who want to learn more about tropical medicine (and, fortunately, the course is in English). There wasn't really anything new in the lecture, but it was a nice review. Then it was back to NMRCD, lunch, more in-processing/in-briefing, and then a taxi ride to the airport to fly to Iquitos.

I'm staying at NMRCD's guesthouse, which is pretty nice--not as nice as my hotel room in Lima, but with electricity, AC, and internet (obviously), which makes it nicer than my accomodations in PNG. I am on my own for food, so we'll see how that goes.

Today I'm off to a cemetery to catch mosquitos, and then in the afternoon, testing them for dengue. Should be interesting...

On my way to Peru

This was written yesterday while I was on the plane. If I have internet in Iquitos tonight, I'll post for today.

And we’re off. Well, I’m off, and quite a few of my closest friends, all crammed into a plane I wasn’t supposed to be on.

So, things didn’t exactly go off to a smooth start today. Concerned that there might be travel problems (thinking about the last time the government bought my plane tickets, when I went to C4 in October and arrived at the airport at 0430 to find that the tickets hadn’t been purchased), I left home on the Metro at 0900 for a 1245 flight, got to Reagan a little before 1000.

And, surprise, surprise, the tickets hadn’t been purchased yet.

Unfortunately, it wasn’t as easy of a fix as it was last time. There’s all sorts of bad weather at Dallas/Ft. Worth, so the emergency line at Carlson-Wagonlit was quite busy. After being on hold for forty minutes, I was told that they didn’t have a copy of the authorization from the WRAMC travel office (just like last time), so I faxed the orders and called back. After another thirty-five minutes on hold, they told me of all sorts of other problems with the orders. Long story short, after spending more than two hours with my phone against my ear, I missed the opportunity to get on the flight I was supposed to be on, and ended up on a flight on Delta (instead of American) arriving two hours later. Unfortunately, the people in Lima had already arranged for me to be picked up at the airport when I arrived, and although I emailed them about the change as soon as I could, I don’t know if anyone was checking email today to get the message.

Guess I’ll find out soon enough.

I’m actually not in Peru yet—just off the coast of Colombia, according to the in-flight map, at 2115—forty-five minutes until I’m supposed to be landing in Peru, and two hours and forty-five minutes until I do.

Unsurprisingly, all of this stuff not going well put me in a rather bad mood (and I can see my parents feigning shock at that—‘what? Lisa not taking two hours of things not going the way they were supposed to, followed by a change in travel plans, well?’), which got me started on the “what am I doing and why am I doing it?” line of thought. I’m going to a country where I don’t speak the language, re-writing all sorts of internship rules while doing so, to research diseases that I find very interesting, but have little more than a passing knowledge of. Oh, and I’m doing this alone (at least until I get to the lab tomorrow morning), and I don’t know if I’m going to have a ride from the airport to the hotel or not.

And I spent six months working on making this happen. What was I thinking?

I’m sure that I’m just inventing all sorts of problems in my head and unnecessarily stressing myself out. After all, I’ve done this before—I landed at the airport in Papua New Guinea in pretty much the same state of mind and with the same uncertainty of the plans, and I ended up where I needed to be without any problems.

According to the flight information screen, two hours and nineteen minutes until arrival.

Visas and burgundy passports (or, visas in burgundy passports)

For everyone who doesn't know what's going on (a group that may include my parents, as they never seem to know what I'm up to, whether I tell them or not), I am taking off for Peru in two days (Sunday, 21 Feb), for three weeks of tropical medicine research.

The DoD (Department of Defense, for the less acronym-inclined) has several domestic and overseas laboratories--one owned by the Air Force, a few by the Navy, and most by the Army--which collectively make up GEIS, or Global Emerging Infection Surveillance. The overarching command, if one could even use that word, is in the DC area, which meant that I got to rub some high-ranking elbows, impressive them with my CV and career goals, and convince them that it's in their best interests to pay for me to go to one of these labs. Peru was chosen because three weeks is a bit short for a research rotation, and since it's in the same time zone as DC, I won't be losing any time to jetlag.

This whole process, of convincing people to let me go and to pay for me to go (two different groups--one to let me go, one to pay for it), started in August, and I got final authorization (ironically, from the 'let me go' group; the 'pay for it' group had already given the thumbs up) much later than that, after months of stubbornly not letting them say no.

Now that that was taken care of... Believe it or not, foreign countries aren't always glad to see active duty military personnel arrive on their soil, regardless of their reasons for being there, so all sorts of country clearance and theater clearance (theater being theater of operations, which in this case is SOUTHCOM--Southern Command) and things going through diplomatic channels and taking forever. The process to get my official (burgundy) passport started... well, I don't remember when it started, but the passport was issued on 11 Jan. Then I needed an official visa to go with the official passport, which requires a resolution signed by the president of Peru, which just came through on Wednesday (so yes, the president of Peru gave me personal permission to enter the country). So I went to the Peruvian Embassy on Wednesday for the visa, and was told that I needed a letter, on letterhead, from my command. Just showing them my orders wasn't good enough. I emailed my program director (who is not technically my commanding officer, but I prefer to leave my commanding officer out of as much as possible, because he loses things. Like leave papers.) and asked her to write the letter, which she did. So I brought all that stuff back again today and dropped it off, and was told to pick up the passport at 5.

Long story slightly less-long: after three trips onto what is technically Peruvian soil, I now have a visa in my burgundy passport.

And assuming no more freak snow storms close Reagan National Airport, come Sunday, I'll have a stamp in my burgundy passport as well.

In case you were wondering how an official passport is different than a normal passport:

This is not my actual passport, just a picture I shamelessly copied from Google. As you can see, it's not blue, it has the word 'OFFICIAL' on it (which blue passports do not), and that little electronic-chip looking thing on the bottom means that there are electronics embedded in the passport.

Anyway, assuming I don't get too lazy while I'm gone, and assuming I have adequate internet connections, stay tuned for tales from the southern hemisphere (it's barely the southern hemisphere, but it counts).