Personal Statement

If you had the opportunity to read my personal statement that I wrote for my application to residency, then you can immediately appreciate the photos above, as were described in my opening paragraph.

Thank you for visiting my blog – it documents mine and my wife’s experiences while living and studying in Peru.  This blog is a compilation of our clinical experiences, cultural experiences, personal opinions, case studies, and travels.  Please feel free to explore, and do not hesitate to contact me with any questions or comments.


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Pisac – Rural Campaigns

While working at the Centro de Salud in Pisac, I had several opportunities to join some of the rural health campaigns.  These health campaigns were basically mobile health clinics run by the Pisac clinical staff, and were set-up in very rural sites outside of Pisac, sometimes as far as 2-3 hour drive away.

I really loved these rural campaigns because it was an awesome opportunity to see how life was like outside of the city….and we were able to provide some basic health services to patients in very remote areas.  Also, the Peruvian countryside is beautiful!

This was our transportation for the clinic supplies and staff.

This is the building we used to set up clinic – in this particular case we set up in the local elementary school.

Setting up…

Some of the clinical staff registering patients as they came through.

An obstetrical nurse attending to an expecting mother.

Once the clinic gets up and running, it can get quite busy…

…and sometimes with unexpected visitors.

Every patient got a “goody bag” of some basic sanitary supplies and a few toys for the kids.

The only problem with working in such rural locations is that often the roads are horrible, which sometimes can be quite a problem.  In this occasion, as seen above, we got stuck in the mud and really had a hard time getting out.  The other problem with being in such a remote location is there is no such thing as calling for a tow-truck.  Check out some of the videos here and here:



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Case Study 9 – Cervical Cancer

Well we finally made it back to the USA, and it definitely feels good to be home.  However, I’m about a month behind in posting, so I’ll be continuing to update the blog periodically…thanks for checking it out.

HPI:  23 yo female presents for follow-up at CerviCusco clinic after high grade lesion (HGSIL) is detected on recent pap smear.  Patient complains of frequent vaginal bleeding, pain/discomfort upon urination, and lower back pain.  She reports being hospitalized twice in the past few months for vaginal hemorrhage.  Per patient, a previous pap smear was done 5 years ago at outside institution, and reported normal.

Past Obsetrical History:
-G2 P1011 (1 gestations, 1 full term, 0 pre-term, 1 miscarriage, 1 currently living)
-Previous cesarean section about 2 months ago.

Past Medical History:  None
Family History:  Unremarkable
Social History:  Patient lives 4 hours outside of Cusco, traveled to clinic alone. Single mother of 2 month-old child.  Denies smoking or drug abuse.  History of early sexual abuse was suspected, but not elicited from the patient.

Cervical Exam:  Upon examination, the cervix was noted to be severely eroded, necrotic, and friable.  Cancerous deterioration of the remaining cervix was noted, as well as involvement that extended into the patient’s bladder.  Parts of the cervix and surrounding tissue were actually sloshing off during exam, with significant hemorrhaging.

Discussion:  The mission of CerviCusco is to prevent cervical cancer, the #1 cause of female mortality in Peru.  While the organization has already done a tremendous job in screening and treating cervical pre-cancerous lesions before they progress, unfortunately we sometimes encounter the tragic and serious consequences when prevention was eluded.  In this particular case, the prognosis becomes even more heartbreaking in such a young patient, and mother of a newborn.

This case highlights some important topics.  First, the gravity of this patient’s disease is very severe, and unfortunately her prognosis is very poor.  Although no imaging could be done to confirm, it is likely based on the cervical exam and history of dysuria that the patient’s disease has already spread to her bladder.  According to the staging criteria (see below), extension to the bladder mucosa or rectum already puts the disease at stage 4, with a very poor prognosis.

From Reference 1:

From Reference 2:

As mentioned previously, this patient’s prognosis is very poor.  Some statistics for patients with different stages of cervical cancer are shown below, and the percentages can be interpreted as the percentage of patients with that typical stage of cancer that survive 5 years after the initial diagnosis.   Furthermore, for stage 4 cervical cancer, there is no curative treatment, only palliative care.  Even more tragic is that there is only 1 cancer treatment center in all of Peru, which is located in Lima.  For our particular patient, a poor, uninsured, single mother who lives 4 hours outside of Cusco, the likelihood of having enough money even to travel and stay in Lima, let alone afford any treatments seems futile.

From Reference 1:

A very very difficult and sad conversation was had with this patient regarding her prognosis.  Because we could not offer her any further treatment options, we discussed several end of life issues (family, finances, spiritual, etc.) before transporting her to a local hospital for acute management of vaginal hemorrhage.

Another topic of interest to discuss is this patient’s extremely young age for having such an advanced form of cancer.  There are two considerations for her disease progression…either she contracted the human papilloma virus at a very early age through sexual abuse, or a very aggressive form of the virus was contracted during her late adolescence, which advanced rapidly to her current disease.  Her advanced disease at such a young age also brings some attention to the current guidelines for cervical cancer screening (pap smears).

Both the American Cancer Society (ACS) and the American College of Obstetrics and Gynecology (ACOG) have recently adapted their guidelines to recommend that cervical cancer screening through pap smears should begin in women at the age of 21, regardless of age at onset of sexual activity.

In 2009 ACOG put out a statement in their practice bulletin as follows:  “In contrast to the high rate of infection with HPV in sexually active adolescents, invasive cervical cancer is very rare in women younger than age 21 years. Only 0.1% of cases of cervical cancer occur before age 21 years.  In a recent analysis of national data from 1998 through 2003, researchers from the Centers for Disease Control and Prevention identified an average of only 14 cases of invasive cancer each year in females aged 15–19 years.  Cancer cases in adolescents younger than 15 years were too few to report. Based on this report and Surveillance Epidemiology and End Results (SEER) data from 2002–2006, this translates to an incidence rate of 1–2 cases of cervical cancer per 1,000,000 females aged 15–19 years.”

While this evidence is very compelling and supports the current guidelines that have been proposed, they can be sometimes be hard to accept in face of a 23 year-old patient, who will die of a preventable cancer most likely in the following few months to a year.  I think this case is a very important less that while guidelines are important and can help guide clinical practice, they may not apply to every patient – each patient is an individual and may need individualized care to better their health and lives.

Lastly, I again would like to promote the work that CerviCusco is doing….and actually last that I heard, there was some discussion of future plans to build a cancer treatment suite on-site in Cusco for patients diagnosed with cervical cancer.  Hopefully, such a center could give incredible hope and treatment for local women, who otherwise would have no other options.  I encourage you to check out more about CerviCusco and their cause.



2.  CAMISAO, Claudia C. et al. Magnetic resonance imaging in the staging of cervical cancer. Radiol Bras [online]. 2007, Vol.40, N.3 

3.  ACOG Practice Bulletin Vol. 114, No. 6, December 2009.

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CerviCusco – Rural Campaign

One of the major components of working at CerviCusco is that they often organize pap smear screening campaigns in rural communities.  These campaigns give rural women the opportunity to be screened for cervical cancer, an opportunity that they would not otherwise have (due to the distance they would have to travel to reach the nearest town/clinic).

 Sign within the main square advertising for free pap smear services.

 Some of the local women waiting in line to be registered…for many of these women, this is the first pap smear they have had in their lives.  On this particular day/campaign, I think we screened about 100 women!  On some campaigns, there have been up to 300 patients screened in one day!

More waiting…

Before any of the women enter an exam room, they are required to watch a brief informational video on pap smear and cervical cancer screening.

What one of the typical exam rooms looked like….very basic

Performing a pap smear…

I had the pleasant opportunity to work with a team of nursing students from Georgia Health Sciences University (GHSU) who spent a week working at CerviCusco.  

Me with some of the pleasant staff who work at CerviCusco.

Once all the samples are collected for the day, they are taken back to the clinic in Cusco where they are later process and reviewed for any evidence of cancerous lesions.  Each patient is informed about a month later of their results, and whether they will need any further care.

Overall, CerviCusco has an outstanding system of cervical screening campaigns, and has already screened (and further treated) hundreds of women within the surrounding rural areas of Cusco, who otherwise would never receive such medical care.

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Bulls Are Bad – Case Study 8 (GRAPHIC)

DISCLAIMER/WARNING – This post is a bit graphic, so please be advised.

The mascot at our current institution, University of South Florida (Tampa, FL) is the bull.  Therefore, we have been fond of the many bulls we have seen here in Peru, and have been trying to take lots of pictures of them, some even while posing with them.  We even have our own Peruvian bull that we take around with us….his name is Teodoro El Toro.

 Typical scene in Peru of locals herding their bulls or other livestock.

Us trying to get a pose with our beloved mascot, the bulls.

However, recently we had a patient come in to the clinic with a horrible gash in her lower abdomen.  Upon further questioning, we found that she had actually been stuck by a bull!

Wound shown in the suprapubic region, resulting from being stuck by a bull.

In this image you can actually see how deep the wound really is, penetrating all the way to the abdominal musculature.

On initial work-up and exam of the woman, she appeared to be in pain, but not in significant distress.  She was alert and oriented with stable vital signs.  We started an IV to get some fluids in her, and then started to strategize how we could close the wound.

In the Centro de Salud Pisac, there is no operating room, only a simple triaje room used for minor procedures.  We put the woman on an exam table in this room, and tried to drape her with as many sterile gowns as we could find, and cleaned the wound with saline and some iodine.  We used local anesthetic (basically, using a hypodermic needle we injected lidocaine all around the wound, but the patient was alert and awake throughout the procedure) to numb the area where we were trying to operate.  After the Peruvian doctor who I was working with sewed up the peritoneum, I took over, and sewed up the remaining fascial layers and skin.  We didn’t have a real drain, so we had to cut a strip from a sterilized glove and used that as a drain.  The patient was then hospitalized at the clinic, and started on antibiotics (I believe ampicillin and gentamycin was used).

Final closure of the wound. You can notice the strip of a white sterile glove that was used as a drain for any accumulating abdominal fluid.

Our patient recovered over the next few days after staying at our clinic, and we finally discharged her, advising her to be more careful around bulls or other large animals.

Interesting case that maybe wouldn’t be as typical in the U.S., thanks for reading.  Also, a graphic reminder to not get too close to the local bulls!


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Jungle Medicine

An elusive monkey hiding in the jungle in the Tambopata region, Peru

I recently got back from visiting the rainforest in the Tambopata National Reserve, near Puerto Maldonado, Peru.  We had an amazing adventure and saw a ton of cool animals (a later post still to come from Janie), but I wanted to show just a few of the many plants that the local people use as medicine.  There were a ton of medicinal plants in the jungle, that are used for all sorts of problems, from headaches to diarrhea to stomach ulcers….there is even a jungle version of Viagra.

This strange tree with vibrant red roots is used to treat kidney stones. The red roots are boiled and made into a drink that helps clear kidney stones.

This plant has same basic compound as acetylsalecytic acid (commonly known as Aspirin) and is used to treat headaches.

Jungle fern that is used to treat liver problems.

This particular tree is called the fire ant houses fire ants which protects the tree from other species...a tree symbiotic relationship in the forest. The bark from this tree is used as an anti-diarrheal. The ants, which contain formic acid, are used to treat some types of arthritis.

This tree, whose name translates to "Dragon's Blood," produces a very dark red sap that looks a lot like blood. The sap is used to treat many skin problems, including bug bites and allergic rashes.

Here you can notice many cut marks in the tree where the medicinal sap has been extracted.

Here you can notice a drop of the sap which appears like blood. When the sap is rubbed along the skin, it transforms to a white cream.

Janie took advantage of the Dragon's Blood sap and used some for a nagging bug bite she had on her finger. She actually noted that the sap cream relieved her itching very well.

Overall, a really interesting experience to see some of the different plants that are used to treat different diseases, the same ones that we treat in the U.S. with completely different methods and medications.  There are no clinical trials or evidence-based medicine in the rainforest, but these methods are still being effectively used to improve the lives of the surrounding communities.

Also, I’d like to congratulate all my fellow comrades at the University of South Florida Morsani College of Medicine, class of 2012,who recently matched into their residency programs.  Awesome job you guys!  For the full story, click here.  For the full match list, click here.





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Helping Hands

While I was mostly working at different medical clinics during my time in Cusco, I did have the occasional opportunity to check out some other volunteer organizations in the area, and learn about their different causes.  One of those organization, Helping Hands, is run by a local couple whose main purpose is to improve their impoverished community, whether by means of health care, construction, education, nourishment – whatever the issue, Helping Hands is looking to resolve it.  I actually met the founder of Helping Hands while playing soccer at a local pick-up game, and he invited me to come help him for a day to work on one of his many projects.  While the organization is involved in many different projects and campaigns throughout the year, this particular project (see pics below), was part of an ongoing construction project to build a local school for small children.

For many travelers in the area, Helping Hands is a a great option to do some volunteer work, because the organization is able to provide some subsidized housing in exchange for work.

Before we started – trying to add on a second floor to this unit.  Not sure if this structure would meet strict building codes, but it’ll make due.

Loading up all the materials we needed for the day…

…and then climbing on up….

Trying to make the right adjustments for some of the wooden pieces.


…and more nailing….lots of nailing.

And the final product after a full-day’s work….still not quite finished, but another step closer to completion.

Thanks again to Mario and the other volunteers at Helping Hands who allowed me to participate in their work and mission.  For more information about Helping Hands, and how to get involved, please check out:


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Medical Volunteering Sites

While working in Peru, I have had several people contact me about some of the different sites that I worked out, and their respective contact information.  As such, below you will find a list of different organizations/clinical sites that I have either worked at or have heard positive feedback.


1.  Hospital Antonio Lorena, Cusco, Peru 

Located in the Santiago district of Cusco, Peru (see map), this is one of the two main public hospitals in Cusco, and generally serves the lower economic class.  Offers most medical services including surgery, medicine, pediatrics, and obstetrical care.  Tuition for foreign students is $100 per 1-month rotation.  At least an intermediate Spanish level is highly recommended, although I have heard that are a select few physicians in the hospital that speak English, and can be requested to work with.

Of note, the hospital is currently going under complete reconstruction (as of spring/summer 2012), which may or may not have some impact on clinical services that are offered.

Contact Information:
Either of the following two persons may be contacted at

Dr. Humberto Alvizurí
Señora Leticia Moreno (she says she more reliably answers emails).

Also located in Cusco (see map), this is the other public hospital.  A bit larger and more central than Antonio Lorena, it offers similar medical services, but in addition has its own infectious disease unit, a burn unit, and neurosurgical care.  Tuition for foreign students is $150 per 1-month rotation.  At least intermediate Spanish highly recommended.
Contact Information:
Dr. Manuel Montoya,
Maria de Carmen,
Located in a small town (called Pisac, see map) in the Sacred Valley of Cusco, this site is a small clinic that offers general medical and pediatric services, as well as obstetrical care.  Generally serves a more rural population, many of whose patients may only speak Quechua, the native language.  Mostly outpatient consults, but also has capacity for few minor hospitalizations and urgent care.  Any more serious cases are transferred to Cusco.  No tuition fees are required, but any type of monetary or other donations are greatly appreciated.  At least intermediate Spanish highly recommended.
Also participates in rural campaigns/ambulatory clinics throughout the country side several times per month.
Contact Information:
Dr. Edgar Claudio Farfan Quispe, 
This clinic is located in Larapas neighborhood within Cusco (see map), and specializes in cervical cancer screening and other women’s health services.  The founder, Dr. Daron Ferris, is associated with the Georgia Health Sciences University in Augusta, Ga and travels to Cusco about every other month.  Excellent experience for students interested in womens’ care, especially improving technical skills in pap smears.  The clinic has the most state of the art facilities in cervical cancer screening within the entire country.  The clinic also regularly does rural campaigns.  There is generally a $500 tuition fee for students not associated with the Georgia Health Sciences network – this fee is used to help maintain the clinic.  The clinic also has on-site housing where all volunteers are expected to stay.  Many of the staff speak English.
Contact Information:
1.  Awamaki
This organization, based out of Ollantaytambo (within the Sacred Valley, about 2 hour drive outside of Cusco, see map)), works with community weavers to preserve their traditions and culture.  Within the organization is a health component that runs mobile health clinics and campaigns.  For more information on their projects, check out their website.  Unless you plan to do a 6 month or longer term, there is a $600 tuition fee for health volunteers, that is used to maintain the health projects.
Contact Information:
This clinic is located in Coya (see map), about 20 minutes further in the Sacred Valley from Pisac.  This clinic is run by an American couple, previously peacecorp volunteers in Peru.  The clinic is very well-run and organized.  The clinic offers general medical services, and has their own operating room.  The regularly bring American teams of surgeons or other specialists for particular health campaigns.  There is no tuition fee, but I believe at least a 1 month commitment is required.  For more info, check out their website.  Some of the staff speak English, but some Spanish is recommended.
Contact Information:
1.  Quetzaltenango, Guatemala – Primeros Pasos
A very well-run and established outpatient clinic located about 20 minutes outside of Xela (Quetzaltenango).  This clinic serves the rural community and offers general medical consultations and check-ups.  Has a large population of pediatrics patients, and the local schools regularly bring students for check-ups.  Also does a lot of health education/promotion work in the local community.  For more information, check out their website.
Contact Information:
2.  Estancia, El Salvador & Chiapas, Mexico – Doctors for Global Health
Doctors for Global Health is a non-profit organization based in the U.S.A. that promotes health and human rights projects throughout the world.  While they have several international sites and projects where they work, the sites in Mexico and El Salvador are two that are more established.  No tuition fees are required, but a longer term commitment (minimum usually 3 months) is usually required.  For more information, check out their website.
Contact Information:


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foto friday 40 – “laundry on Tequile”

Island of Tequile, Lake Titicaca

. . . . . . .

getting closer . . . we’re at May 13th’s foto friday!


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foto friday 39 – “harvesting at dusk”

. . . . .

Amantani Island, Lake Titicaca

May 4th’s foto friday.

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