The rest of our photos from Peru and Ecuador.

Here are the multiple photos we took.

Our Week in Cuenca

Once we got settled in Cuenca, our days sunk into a routine.  This was my eight mission so things were similar and at the same time different.  Like for example this week we started operating on Sunday.

We would get up around 0600 and have breakfast in the hotel's dining room.  This was a buffet with heuvos of course, little pancakes, bread, bacon or sausage and fruit.  The hotel makes an incredible fruit juice, a different fruit every day,  All this with coffee which we diluted 50:50 with hot milk.   The best part of this was getting to eat with members of the team as opposed to at home where I usually eat breakfast alone before heading off to work.

One we finished breakfast we would walk throught the streets of Cuenca to the hospital.  Cuenca would be bustling early in the moring.  We had a choice of routes, we could walk past the cathedral or past the food market which would just be getting started.  We would descend down to the Tombabomba river, cross it and then walk to the hospital.  The tile sidewalks were slippery if it rained or as happened that week when a volcanoe deposited a layer of volcanic ash.  Once there we would change into our greens and set up for the day.  Mary worked on the floor and the nurses after taking report from the local nurses who covered over night would get the first two patients for the day ready while looking in on the previous day's patients.

All our cases were planned spinals.  In eight years we have only done  1 case under general and have been fortunate to have never had a failed spinal.  We are of course ready to proceed to a GA if necessary. 

Above is a "selfie" of my in the OR.  I like to tape things on the wall as you can see.  The hose behind me is a Bair Hugger hose blowing cold air because the rooms are very hot.

This is the machine and monitors that the hospital provides.

These are my anaesthetic supplies.  We use a tackle box to store drugs along with this plastic set of drawers.  As you can see I am just as messy in Ecuador as I am in Canada.

This is a fairly typical case that we did.  You can see that she had the other side done in the past.  You can see the destruction of the joint on the right side.  These patients are not getting their joints done to improve their golf game!

Here are some of our team operating on a patient.

We were able to run two rooms and did 4 patients in each room for a total of eight patients a day.  This usually took us until between 1700 and 1900 every day.  The nurses of course stayed later.  

At the end of day we would walk in groups back to the hotel, stopping to shop sometimes.  Usually a cold cerveza or a glass of vino tinto was waiting for us in the hotel bar.  

Dinner was usually served around 1930 in the large dining room.  The suppers were excellent as was the company.  Towards the end of supper each group did a report of their day; some were funny, some were touching.   Supper tended to last until around 2100; there was often time only for another drink, a chat or check the emails before we went to bed.

On Thursday of the week, the surgeons had an educational dinner with the local surgeons so I took advantage of this to go out to Santa Lucia with Mary, Amy the resident who came with us and the floor nurses,  We like to go to this restaurant at least once a year.  It is a beautiful room and serves a variety of Ecuadorian and other food.  We had a leisurely dinner there which didn't wrap up until about 2200.

Friday was only a half day as we had worked half a day the previous Sunday so we did only 4 cases in two rooms.  That meant that after packing up I was able to get out of the hospital shortly after noon to walk back to the hospital.  Mary had to work the rest of the afternoon but she got home around 1600 and we were able to get out and do a little shopping including buying her a birthday present because it was her birthday.  

Normally on Fridays the local rotary club invites us to their hall for a dinner, speaches and party in honour of our hard work.  Because it was Mary's birthday I was able to get out of this and we went together to Tiestos for a excellent meal together.  We got back to the hotel and chatted with some of the OR nurses who had not gone to the party because they had to pack before heading off to bed.

The urinal at Tiestos.

Our Mission the first few days.

Our Medical Mission; the first few days.

When we do take a South American vacation, we usually take it after the mission so it almost felt like a bit of a downer as we left Peru knowing we had 6-7 days of work ahead of us.  This feeling evaporated as we met our team.  Someone asked me in the past why I keep coming back and I replied it was the team.  Of course we all want to help people less fortunate than us but it is a lot easier being part of a "band of brothers (and sisters)".  

Every mission is a little different but we made some fairly major changes this year.  Usually the routine is to arrive in Cuenca on Saturday after spending some time in Quito and Otovalo.  This year however largely because of the new airport in Quito, the group flew to Cuenca on Friday after arriving Thursday night.  We of course came from Peru which was different.  Usually Saturday is a fairly relaxed day of unpacking and settling in.  This year we did a combined follow-up and pre-assessment clinic, with the plan of starting cases Sunday afternoon.

Clinic is an exhausting slog.  People come from all over usually with about 5 friends and relatives so the area is congested.  You do have to remember that just about all of these people are desperate for help.  The area where we see the patients is less than adequate for assessment by nursing, orthopaedics, pediatric ortho, physio, dental and oh yes, anaesthesia.  This is complicated by the fact that every one of these groups needs 1-3 translators and we certainly had nowhere near that critical mass this year.  In addition not knowing  from year to year what type of space will be available makes it hard to plan in advance.  This year our crowd control was much better which made the congestion in the clinic area less and we were able to see about 150 patients over 8 hours, 48 or so might be going for surgery which meant anesthesia had to see them as well.  On days like this it is really important to keep repeating the mantra "it is all about the patient".  

We limped back to the hotel and a cold beer followed by our first of the excellent Inca Real meals and then off to bed.  

We arose the next morning and ate our first excellent Inca Real breakfast.  Some people went to mass but I decided not to spend one of my few remaining hours of freedom on a hard pew so we looked around the markets before Mary and I headed over the hospital around 1100 to set up for a planned 1200 start time.  

 I was actually in the cathedral does that count?

Most of my anaesthetic equipment I had unpacked the day before and I was relieved to find out on arriving in the OR that the hospital had left the monitors in this year.  Normally the hospital has stripped the OR of monitors leaving us to depend on the ancient monitors we leave down and the borrowed monitors we bring down. 

We were able to get our first 4 cases done and got home in time to watch the Super Bowl in the bar and the hotel even brought down our meals.  Soon it was off to bed to rest for our first full day of work in the OR.  

Peru to Ecuador

As I said we had an awesome two days travelling to and from Machu Pichu but all good things have to come to an end and it was time to get to Ecuador for our medical mission.  This was to take two days.

Our flight was booked for 1250 so our driver had promised to come at 1100.  This gave us some time to sleep in, have a leisurely breakfast and even do a little half hearted shopping.   Our driver was late which was a little anxiety provoking, I should get over this, drivers are always late in developing and developed world.  We arrived at the airport and on checking in were told our flight was an hour late.  No problem, we were only flying to to Lima with no connecting flight.      We expected to have a few hours in the afternoon and evening to explore Lima which we had never visited.

Getting through security we entered the departures area which even by standards of the developing world was full and very busy.  There were no seats available and people were sitting and lying on the floor.  Our flight was not posted on the departures screen which was okay because there was only room for 4 flights and we were really early.  We had an indifferent coffee, and walked around the departures area in turn.  As time went by our flight was still not posted.  I went to a LAN employee and asked for an update and was told our flight was departing at 1350 as we had been told.  When it finally appeared on the board, it was now to leave at 1430.  About 5 minutes later, it disappeared from the board.  

It was pretty clear that something was wrong.  People were starting to yell; flights arrived, hardly anybody seemed to be boarding flights.  We went to the gate where our flight was supposed to leave before it disappeared from the screen  The screen was blank there but people were lining up.  I went up to the LAN employee at the gate and asked again for the status of out flight.  The man pointed out to the line and said stand in line there. 

About half an hour in line we started to board our plane.  Someone in line said that the pilots had been refusing to take off.  Some said it was a labour dispute, some said it was because of the weather.  Personally if my pilot thinks it is unsafe to fly, I will take his opinion over some MBA in head office and I also like my pilot to be happy.  I am kind of funny that way.  Anyway as we were boarding the plane, people not in line were yelling at the staff.  It appeared that our flight was going ahead while flights that were supposed to leave earlier were still waiting.  Not really fair but you have to look after ones self of course.  We eventually took off about an hour after we were originally supposed to land in Lima.  It was otherwise an uneventful flight.

A man from our tour company met us at the airport.  He had waited 3 hours for us so it was nice of him to hang around.  He half jokingly half serious told us we were going to have to leave a larger tip.  We had about a one hour car ride into LIma, the last bit driving along the Pacific Ocean.  The tour company had booked us a hotel 3 blocks from the beach.  This was too bad as we arrived around 1900 so really didn't get to enjoy it.  We just had a beer on the roof-top bar, ate dinner in the hotel restaurant and off to bed,

Our driver picked us up at 0850 the next morning and it was off to the airport through the morning rush hour traffic in Lima.  We got dropped off at the airport, negotiated a large line-up to  check in, got through security and to our gate.  Did I mention our plane was late?  Finally we took off for Quito.  I was able to shame the flight attendant to move me to an exit row.  After 2.5 hours we started descending to Quito but then suddenly started climbing very suddenly.  The flight attendant ran over anxiously to check if the exit row was unobstructed which was a little unnerving but we did land uneventfully.

This was our first visit to the new airport in Quito which was built outside of town.  No more descending perilously close to houses and apartments.  It is a very nice airport compared to the old one.  Even with our late flight we had a 4 hour stop-over.  The Quito airport has unfortunately been taken over by American restaurants so we had to eat at a "Fridays".   This is a pity because Ecuador has its own unique cuisine and frankly I can get quesadilas, ribs, burgers or wings in Canada.  We ran into some stragglers from our mission who were flying on another flight to Cuenca, the main group having flown earlier that day.  It was nice to catch up even though we have been meeting monthly for the last six months.

Our flight to Cuenca eventually took off.  The flight to Cuenca is a short flight where you are either taking off or landing.  On arrival our luggage was actually waiting for us.  We had planned on taking a taxi to the hotel.  Our hotel while not the Hilton or Marriott is a place where a lot of tourists stay so it was a little amazing that the first taxi driver didn't know where it was, even when we gave him the street it was on.  The second driver didn't either but with the help of an English speaking physician we met on the plane and a phone call to somebody, he figured out where it was.  Our taxi driver had the philosophy common to many taxi drivers in Ecuador which was that the only way to drive was to drive as fast as possible, maintaining the minimum distance between him and the car in front of him.  Plus my seat belt didn't work.  I haven't been so relieved to get out of a taxi, since the last time I took a taxi in Ecuador.  I paid the man $3 and  someone from the hotel got our bags.

The Inca Real our home for the week.

It was a relief to finally get to the Inca Real where I have stayed 7 years in a row.  The staff even knew our names and we got checked in quickly.  We exchanged pleasantries with the people who had arrived earlier.  I had resolved in the Quito airport that as soon as I got to the hotel I was hitting the sack but we ended up talking,laughing and drinking until 2300 when we finally hit the sack in our usual room.

Sacred valley and Machu Pichu

At about 0800 our guide Timas and our driver met us at our hotel to drive to Agua Callientes via the sacred valley.  We packed just enought clothes for overnight in our bags and headed out.  Our driver headed out thru the narrow and steep streets of Cusco until we left town and got on to the highway.

After an hour or so we pulled up at a craft area where we got out.  The people at this craft area put on a demonstration of dying, spinining and weaving alpaca and wool.  Somebody brought over a class of coca tea and we watched the demonstration.  After of course we had to buy some stuff and then we headed out.   

About 5 minutes later we stopped again and got out of the car.  With our guide we walked through the streets which had crafts for sale.  We arrived at a church which our guide pointed out was built on the foundation of an Inca wall.  We kept on going, rounded a corner and came upon this.

Walking on a little further we can upon these terraces with this spectacular backdrop.  At the bottom of the ravine according to our guide was the Inca trail.

We drove on stopping to view this:

The sacred valley is at the bottom.

We then drove to Moray below.  This is not the work of aliens.  Essentially these are sinkholes due to tectonic activity and the Incas terraced them.  The purpose of these terraces was agriculural experimentation as each terrace represents a separate microclimate.

We then went on to this impressive Inca site.  We climbed up the terraces and walked around coming down by a different route.  

 The town is overlooked by an Inca man.

After spending about 2 hours at this site it was off to catch the train to Agua Callientes.

 

The train ran along a raging river quite often right above it.  It was possible to see Inca terraces along the side of the river.  The scenery was impressive but at the same scary.  We rode gradually downhill and the vegetation gradually changed to jungle.  An hour and a half later we pulled into Agua Callientes and got off the trail.  We walked through a gaunlet of vendors before getting to our hotel.  

Agua Callientes sits at the foot of the mountain that is Machu Pichu.  It is an impressive setting with steep mountains rising up on all sides and the raging river running through it.  It is a mixture of a tourist town and a boomtown with many buildings half built.  One expects to run into Indiana Jones or a James Bond villian.  

Our guide met us at 0800 the next morning and we got into a long line-up for the bus to Machu Pichu. It took us about 30 minutes to get to the front of the line.  

 It was raining moderately hard.  We got seats at the front of the bus.  This was a mixed blessing.  We did get excellent views as our bus navigated the switchbacks, however we got to see how close our bus was to the end of the road and how steep the drop was below us.   Many switchbacks later our bus driver stopped, turned the bus and started backing up the mountain.  Great, I thought, he is going to show us how good a driver he is by driving the rest of the way in reverse,   He was only parking however.  The road had been blocked earlier by a rock slide and we had to get off the bus, climb some stairs and get on another bus, arriving shortly at the entrance to Machu Pichu.  

We negotiated the entrance relatively fast and this is what we saw right away,

I had expected Machu Pichu to be impressive but had no idea how impressive even in the early morning rain and mist.  Aside from the terracing and buildings the natural surroundings were sherely awe inspiring.   It is hard to think of a place where man made and natural features are juxtaposed so intimately.  

It was raining moderately hard in the early morning.

As our guide walked us through the ruins the weather improved and we were  soon able to see the surrounding mountains.  Below is the temple of the sun.

We had tickets to climb Warnu Pichu the steep peak below but declined in view of the rain and the narrow stairs.  Later we climbed up the Sun Gate trail and were able to see this vista below us.  

 

The Sun gate was about and hour out and 30 minutes back. The Inca trail arrives at Machu Pichu at the Sun gate so maybe one year we will walk thru it.  

Our guide had left us so we walked down to the bus, making not to sit at the front and 30 minutes later we were in Agua Callientes where we went for pizza and Mary had an Inca Cola,

An hour or so of shopping near the train station and we boarded our train with our guide.  To distract us the railway put on a fashion show of alpaca goods and Mary bought even more alpaca.   We didn't take the train all the way to Cusco but got off at the first station where we had caught the train and our driver was waiting for us and we had a 1.5 hour drive back to Cusco where we checked back into our hotel.  

We were pretty worn out, we had had two pretty amazing days.  A light supper, a couple of glasses of wine and off to bed.

Peru

Our trip to Peru started as most long trips start with a way too early wake up.  At least this year we were spared having to wrestle two hockey bags full of medical equipment and instead just had too roller suitcases and backpacks as carry on.  Our taxi arrived on time and we were at the airport over 2 hours early where a moderate sized line-up had already formed.  Pretty soon we were checked in and with our Nexus cards US customs was a relative breeze.  The agent almost smiled this time.

We (I) ate a large greasy breakfast near our gate washed down with copious amounts of coffee and took our first dose of acetazolamide.  We would be heading to 13,000 feet pretty much our first day in Peru and it was time to start peeing out that bicarb.  Eventually we boarded our plane.  We had paid extra for exit row seats so had lots of leg room which enabled us to alternately sleep and read during the 3.5 hour flight to Houston.

On arrival to the George Bush airport we headed straight to Pappadou's for a little seafood and of course a beer.

That killed an hour or so of our layover so we walked around, Mary bought a watch, I bought a cap and soon we were able to board our plane for the long flight to Lima.  

Thanks to United's incomprehensible zone booking system we got to board last.  As I mentioned I paid extra for extra leg room but by the time I had got to my seat the adjacent seat was occupied by an ancient haridan
with elbows like Gordie Howe who had already taken over 2/3 of my seat as well.  This lead to 6 hours of trying to push her out of my space and being pushed back.  I tried to sleep but every time I drifted off to sleep I got an elbow to my shoulder or the drinks cart came by and knocked my other elbow.  

We eventually landed in Peru, breezed through customs, (Canada should send their agents down to train there) and after waiting a long time for our luggage we walked across the street to our airport hotel which had been booked for us.  It was now close to midnight local time.  We even turned down the welcome drink the hotel offered us and headed straight to bed.  Oh did I mention we were supposed to check in for our flight to Cusco at 0730 the next morning.  It is amazing how sitting on your ass for 10 hours tires you out and we slept like logs.  

We were up at 0630 the next morning got our bags packed (well really we hadn't unpacked them) and got down to the buffet breakfast.  Like most airport hotels there was a polyglot of different nationalities; we saw many tour groups and wondered if we were going to be joining them.  We then grabbed our bags, rolled across to the airport and checked in.   Like most airports in South America it was a hive of activity but we were able to get checked in and through security relatively quickly which of course meant all the more time sitting at the gate before lining up to get on a bus to our plane and boarding. 

It was a short flight to Cusco, a little cloudy but with some mountain views.  We had our first glass of Inca Cola which tastes more like Cream Soda than cola.  Eventually our plane cork-screwed down into the Cusco airport and we deplaned.  Now came the moment of truth, were we going to get the dreaded altitude sickness.  I was expecting to gasp for air as I walked off the plane but was pleasantly surprised.   

We picked up our luggage and met the lady from the tour company who was waiting for us and we got into a van to drive to our hotel.  Pleasantly we found that we had a private tour and that there was just the two of us, a guide and a driver.  Not that we are anti-social,  we have met a lot of nice people in tour groups; we have also met some real disruptive types.    The lady from the tour company told us that we would be taking it easy that day.  She cautioned us to take it easy, drink lots of water and to avoid red meat.  She also encouraged us to drink Coca tea which she told us would be freely available in our hotel.   Sure enough after checking in and getting oriented about our trip, the manager took us to the lounge where this bowl of coca leaves:

was waiting next to a container of hot water.  He placed a fistful of leaves into a small paper coffee cup, let it steep and handed it to us and we drank it.  I wasn't sure what to expect but I didn't get any urges to disco dance, play in the NBA or be mayor of Toronto.  

Cusco which the Lonely Planet describes as a tourist trap is full of a wide variety of visitors ranging from back packers to elder hostlers.  Not sure where we fit it.  It is a Spanish colonial town, a lot like Cuenca but more developed for tourists.  The coca tea gave us energy and we walked up towards the main square.  As we approached it we started coming across boutiques selling beautiful alpaca clothing, much finer (and more expensive) than we were accustomed to seeing in Ecuador.  Between shops street hawkers flogged their wares.  The main square is quite large with churches on two sides and stores and restaurants occupying the remainder of the perimeter.  

Starbucks has arrived in the high Andes but most of the restaurants are authentic.  A little hungry and just wanting to sit down, we accepted the entreaties of a man on the street to eat at his restaurant where we both had a ceviche of the local trout which was very good.  As well we were able to sit on a small balcony overlooking the square.  

More shops, trying on sweaters and back to the hotel where I had the massage I had booked earlier.  Later in the evening we walked to the restaurant that the tour guide had recommended.  We took her advice not to eat red meet but compromised by having a bottle of Chilean wine with it. After that a walk  home and off to bed where we had a good sleep in the thin air.  

We got up around 0700 and ate the buffet breakfast in the dining room.  At 0900 our tour guide  arrived and we went on a short walk to Santo Domingo church.  This church was built on the site of a large Inca temple and the Spaniards simply plastered the wall and built their church around it.  An earthquake in the 1960s revealed the original Inca structures which were then excavated and restored. The Incas built their structures with large blocks which were cut accurately enough to fit together without plaster and were able to withstand earthquakes.




After exploring the ruins and the church with our guide, our driver picked us up and we headed through the narrow busy streets eventually climbing up high above the city where there were more Inca ruins.  

This huge site originally a temple to the Milky Way is still only partially excavated.   These photos really do not do it justice.


 Our local guide Dimas.  We have been lucky in our travels to have lots of good guides and he was one of the best.

Leaving this site we drove higher up to what was originally an Inca way station.

We also explored one more set of ruins dedicated to worship of the Puma before returning to Cusco where we toured the cathedral and said goodbye to our guide for the day.  

We ate lunch at a restaurant suggested by our guide.  He told us it would be possible to eat Cuy (guinea pig) however they require advance nice so I had duck and Mary had a quinoa tabouli.  I also sampled an excellent (dark) local beer.  

Then it was more shopping.  We first visited a market much like the ones we knew in Ecuador.  

It was there that I met this character.

I thought about bringing one home as a trophy for Surgeon of the Year but I suspect our customs would confiscate it. 

We next went to a more upscale store and each bought a nice Alpaca sweater.  Then back to our hotel  but not before Mary met these people.

Our adventure continues tomorrow as we visit the Sacred Valley and then on to Machu Pichu.