From Jessica Gimbel, Nursing Staff

The most memorable patient I had was a teenage girl who came in for a scar revision; her upper torso was so badly burned that she had lost most of the range of motion in her neck. It was somewhat difficult for me to communicate with our patients since they spoke Spanish and my only background in the language dated back to high school. Because of this, there was frustration on both sides and I couldn't tell whether or not she trusted me as her nurse. She was even more unhappy when she had to stay overnight because we had so many surgeries scheduled. 


However, when her name was called the next day, she was overjoyed; I put on her cap and booties and wheeled her to the OR. Right before I left, I was surprised to hear from one of our translators that she was asking if I would be there to take care of her after surgery- I was surprised and flattered, but also felt an even stronger sense of responsibility to make sure that her recovery would progress as smoothly as possible. When she came into the recovery room, she was unconscious and shivering. Ten minutes and five blankets later, she woke up and looked me right in the eye. "Is it over?" "Yes."

The next day (after a few rounds of pain meds and deep breathing), I showed her how to take care of the surgical site and gave her discharge instructions. After paying close attention to the teaching and getting dressed, she was ready to leave. With a big smile on her face, she gave us the customary hug and kiss on the cheek, then squeezed our hands with a sincere "Gracias!"

This girl reminded me of my reasons for coming on the Ayacucho medical mission- to help treat those in need, and to do so with a sense of compassion and mutual respect. This was my first medical mission, and it helped open my eyes to the world while simultaneously showing me the avenues through which a single person can make a difference.

Anonymous entry from a General Volunteer

I came, I saw, I…..learned. As a general volunteer who spoke little to no Spanish, I had expected to be set aside as some extra, called upon only for menial labor. However, it turns out that each and every member is an integral part of the system. On the first day, I was placed in the pharmacy, where I was part of the team that dispensed the medication. Throughout the week, I was placed in various other services including OR, where I observed the surgeons perform dozens of miracles, family medicine, where I learned about the basic examination techniques, and "crowd control", where I helped other volunteers keep order in the waiting area as dozens of patients wait their turn. I learned so much from this trip and I met so many amazing people. Hopefully I’ll have a chance to come back next year. 

from Candy Sopp, Licensed Clinical Social Worker

Mark De Antonio, Mission Psychiatrist, and I were asked to see a 20 year old female  patient who initially came to the mission for medical care regarding a broken nose.  The mission surgical team decided that the patient did not need surgical intervention at this time, but referred them to us to address her immediate mental health needs.  


We initially met with the patient and her father.  After talking with them both together and getting some family history and learning how she broke her nose, we asked to meet with the patient alone.  This was a challenging case to deal with due to the family dynamics and family violence which led to the patient having a broken nose.  We were finally able to work only with the patient without her father in the room to provide crisis intervention to her regarding her current home situation.  


We were also able to refer her to the mission mental health clinic, COSMA for ongoing mental health services including continued medication management and counseling.   The father of the patient was adamant that she needed surgery regarding her broken nose due to the potential negative psychological effects of not doing surgery.  However, he then reported if the mission does not perform surgery on his daughter, she will hound him for the money to have the surgery, $2,000.   In talking directly with the patient, she told us she was fine with not having surgery, but was extremely distraught about the home situation and not feeling safe in her own home.  We provided her with a information for a domestic violence shelter in the community as an additional safety resource.   She was open to the resources we provided and  willing to follow up.  It became very important to speak to her alone as her father was not ultimately a support to her in achieving safety and psychological support.  


This was a rewarding experience for us to be able to help this  patient.  We also realized in working with this  patient that surgery is not always the answer.  In cases like this, the mental health interventions we can provide are of primary importance.  

from Traci Fortney, OR Nurse

What another rewarding year for me!  This was my third year in Ayacucho, and despite being exhausted from so many long, grueling days in the OR, I left once again with an immense feeling of satisfaction of being able to help so many people.  The most meaningful part of my week was being a part of the operations for our kiddos that came from so far away to have their cleft lips repaired.  I was able to meet the kids from Puno Sunday morning as they arrived at the hotel just as our plastic surgeons walked in for the airport.  Seeing the looks of desperation on the parents' faces as the surgeons put down their bags and sat in the courtyard to examine their new patients was saddening.  But as I met the surgeons, I knew the adorable children were going to be in good hands.

Monday morning rolled around and the OR got off to the normal slow start as we tried to relearn where everything was and what supplies we had available.  But as soon as the first cleft patient rolled in, we got down to business.  It was amazing to watch how Dr. J and Dr. Liu marked out their incisions on the lip and figured out how they could move tissue around to turn the cleft into a natural looking lip.  As we put the final sutures in, I had such a sense of accomplishment as I knew we just helped to change this child's life forever.  That feeling continued as the workday moved into the "worknight".  Yes, we had late nights in the OR all week, but we were able to touch so many families' lives that the missed sleep was worth it.

I am already counting down the days until I can return to Ayacucho and be back among the people of the Andes that I have grown to love so very much over the past few years.  As I was able to tell the director of the hospital at our farewell dinner when he asked who in the group was Peruvian- ¡soy peruana en mi corazón!

from Irit Barak, Recovery Room Nurse

I am back in Los Angeles still speaking Spanish, and my friends can't understand me. When went to eat lunch with friends, I still tried to pay with Peruvian money (Nuevo Soles).  I feel like I am still there.   I had great time and I am very impressed with how Loretta (the Nursing Director) worked with each one of us. Today, I'm spreading the word in Kaiser and I already have 3 nurses that would like to join us.

from David Daar, medical student

The cool thing about ultrasound is that it doesn't need translation.  What you see on the screen is what you get, and for the patients in Ayacucho that haven't seen technology like this before, being ultrasounded is both useful as a diagnostic and a psychological therapeutic.  While seeing patients with Dr. Cesar Aranguri, mission director and cardiologist, we performed a cardiac ultrasound exam on nearly every patient that came in. There was one rare case in which we used ultrasound to diagnose a patient with rheumatic fever - matching the clinical signs with the valve defects identifiable on ultrasound helped Dr. Aranguri effectively care for his patient.

But for the most part, our patients presented with muscular chest pain, in which no significant therapy was needed.  So Dr. Aranguri performed what he called "therapeutic ultrasound" on these patients.  Examining their heart and telling them it looked healthy and strong gave them a piece of mind they didn't seem to get in any other way.  This is one of the powers of medical technology, especially in areas like Ayacucho, and by helping lower the anxiety level of these patients, ultrasound proves to be a powerful tool for mission trips like these.  Hopefully next year, we can find a way to bring another machine or two!

from Susana Gutierrez and David Chen, volunteers

Our experience in Ayacucho has been unforgettable and truly wonderful. We specifically remember a mom who came to our clinic because her daughter had a foot infection. The mom had walked two days from the jungle with the daughter who had an infection and her younger daughter on her back. Amazingly, they had not eaten for two days. It was an extraordinary case of strength and perseverence. Thankfully, everything went well and the mission was able to finance their stay in Ayacucho, as well as their return to the jungle. What we have learned here in Ayacucho will forever change our lives. 

from David Daar, medical student

Today I worked in the gynecology dept., and it was a very positive experience.  Week 2 began today, and we had two new OB/GYN docs leading the clinic, Dr. Aliyah Khan and Dr. Frank Goicoechea.


I always had an impression of GYN that it wouldn't be for me, but my experience today really opened my eyes to the field.  It is a great mixture of clinic and procedures - and if I want to go on mission trips like PAMS in the future, it is a highly requested and needed specialty.  I really got my money's worth today.  We saw over 45 patients and scheduled several operations for later in the week that will significantly improve our patients' health, including 2 hysterectomies to prevent continued excessive bleeding and possible endometrial cancer in the future.

Another aspect that I learned a lot about today was the dedication to patient comfort and modesty - something especially pertinent to GYN.  Moreover, in general there is a high level of modesty amongst the Peruvian community, and being able to respect that while still effectively examining a patient was a task that takes both finesse and compassion.  Our docs today were phenomenal role models, and I appreciated how much time and energy they spent teaching us.

Another solid day in Ayacucho, can't wait for tomorrow!

from Julio Mendoza, translator

Day 1:  From the start, I anticipated that I would be busy all day helping to interpret for scores of patients, so the long hours came to no surprise.  I was also aware that people had traveled tremendous distances and would have endured hunger and thirst to have the opportunity to see a physician for the first time, so I was sympathetic to their physical status when they met with the doctor.  However, what shocked me the most were the tears shed by several of the mothers (in Pediatrics) when they received reassurance from the doctor that their babies would be okay and that they need not to worry.  It was at that point that I realized the importance my "grain of sand" played in the overall success of the Mission.  Those mothers would finally be at peace because she had done everything she could to ensure the best for her child -- and to be honest, I would have done the same if I had a child of my own and didn't have the many fortunes I have available to me.


Day 2: Today I worked as a floating interpreter.  I wondered if patients were scared of enduring surgery.  I know that if it was me, I'd be frightened, but I suppose that at some point having less pain is better than the alternative.

A mother who had limited resources gifted a lipstick to the pediatrician who went out of her way to refer her to an autism specialist.

I noted that is is becoming more and more difficult to turn down surgery patients due to high demand and limited resources.  As I walk around the hallway, patients crowd around me to ask if their surgery appointments will be honored, and all I can tell them is that surgery is no longer available because the spaces are filled.  Despite this, they beg me to intervine for them to the higher authorities, and all I can do is ask one of the directors to reconfirm what I had already told the patients.

Whether coming from a doctor or non doctor, there is no worse feeling then telling someone that they cannot receive surgical treatment because they are not sick enough to receive it (although I will add that doctors can probably handle it much better than I ever could).

Day 3: Despite all precautionary measures, I managed to come down with a mild case of diarrhea.  Fortunately, the pediatrician whom I was working with gave me some medication that quickly took care of the problem.

Most of the day went smoothly.  (I was even able to take some pictures of staff and consenting patients).  During lunch, I was able to get to know the pediatrician at a personal level, and it amazed me how similar our past experiences are.  The lesson that we learned from each other is that "that which doesn't kill you makes you stronger'.

On our way home from the clinic, my wife and our mutual friend (both of whom are doctors at the Mission) came across a young girl on the sidewalk experiencing an epilepsy attack.  We were quick to rush over and provide assistance, but the girl's two friends informed us that she would be fine.  Not being a doctor, I stood on the side and observed the scene with a sense of pride in that we were positively representing our program.  Our pediatrician's information was provided to the girl, and we expect her to show up to clinic tomorrow.


Day 4:  I hadn't even arrived to the door of the clinic, when I get flagged down by a familiar face.  I can¨t quite remember the details, but the distraught lady immediately starts telling me that her family showed up to surgery for the mother-in-law at 7am as instructed by the surgeon, but the surgeon wasn't there. I suddenly remember the case.  What can I tell her?  My guess is that the surgeon got wrapped up with another urgent matter and could not meet her appointment.  I rush to the program coordinator, who also remembers the case, and he immediately calls the surgeon via cell phone -- a surgery spot has been reserved to remove the tumor, but the surgeon needs to re-confirm the possible complications with the family before the procedure can be done, so she will meet with them one last time when the surgeon is done rounding on her patients. Whew!!!

I wasn't assigned to a specific clinic today, so I played the role of floating interpreter.  I wasn't as busy as days past, but I did feel privileged to be called on for the more complicated cases, when detailed communication was essential.  I did have some time to chat with the nursing staff and some of the patients, and they look forward to our return next year!

The day is done, and I¨m looking forward to visiting the orphanage tomorrow afternoon!

from Michele Torosis, medical student

Friday was one of those milestones all medical students (not so) patiently anticipate, the first time scrubbing in on a surgery.  After spending Thursday with one of the general surgeons, Dr. Sharp, seeing the far less glamorous clinic side of surgery, I was able to scrub in for the first time in the glamorous OR of Ayacucho.

The morning started with the anesthesiologist, Dr. Rinehart, guiding me through starting an IV on the patient.  After that I learned the sterile procedure for scrubbing in.  Finally my hands were inside the patients abdominal cavity.   The surgery was a palliative gastrectomy on a 80 year old lady with a large gastric tumor which had most likely metastasized.  Due to the high cost of a CT scan, the surgeon had decided to proceed with the surgery without one, deciding that a CT would not change the treatment of the patient.  Having done the fore, mid, and hindgut dissections in anatomy class, I felt confident knowing exactly where and what I should find in this region.  However, with blood actually coursing through all the arteries and veins, I learned I couldn’t even identify for certain the middle colic artery.  The two general surgeons verbally guided me through what they were doing.  My job was to retract, cut sutures, and suction.

Freeing the stomach from the greater omentum and the transverse mesocolon was the most tedious part of the surgery, not having the same tools as in the US.  After the tumor had been isolated and the stomach freed, it was time to remove it.  The tumor had taken over the entire greater curvature of the stomach and the majority of the stomach had to be removed.

Four hours later, my back started hurting, my hands were cramping and I was seriously starting to question my stamina.  Surgery has always been something I am interested in, but what if I am not strong enough to make it through back to back to back 5 hour surgeries?

After the patient was closed and bandaged up, I put in a foley catheter and helped the anesthesiologist transfer her to the recovery room.  Watching the patient quietly rest in post-op, surgery a success, I felt for the first time in Ayacucho that I had helped significantly improved the life of someone.  I had been a part of seeing the patient in clinic, taking her history, examining her, scheduling her surgery, and removing her tumor.  This experience was a nice finale to a diverse week of experiences and has excited me for our second week in Ayacucho.

from Mark DeAntonio, Psychiatrist

A frustrating day as less referrals than expected but the mental health team consulted on an inpatient five year old boy recovering from surgery after serious facial lacerations to the face from a dog bite. Both patient and father were traumatized and we will continue to follow them while in the hospital.  The plastic surgery team did an amazing job masterfully correcting significant facial trauma.

from John Billimek, volunteer coordinator

Leandro, his dad and me.

Today was an incredible day.  I woke up early, walked out to a beautiful breakfast and greeted the last set of volunteers arriving from the airport.  Among them were Perry Liu and Payam Jerrahnejad, two accomplished plastic surgeons exhausted from traveling.  I knew that six kids from the far away agricultural town of Puno would be coming to the hotel to see them sometime today.  One of the six is a shepherd’s daughter.   Three were scared to go into the elevator as they had never been in one before.  And none had flown in a plane before they were sponsored to come to Ayacucho to have surgery to repair their cleft lips and palates at the mission. 

Just as Perry and Payam were putting their bags down in the hotel’s courtyard, all six kids came in with their parents, ready to be seen.  Three had already completed their surgeries the week before with other mission doctors, and the other three were being evaluated to determine the best procedure for them.  As the surgeons examined them with care, we heard sad stories like one of the kids being called “devil child” back in the village because of his appearance.  The work the surgeons set out to do is so important on multiple levels.

The kids were as cute as you can imagine.  The ones that were old enough to walk were decked out in sneakers and ball caps and priceless smiles.  The babies were resting comfortably in the folds of the their mothers scarves.  We’ll be able to address many of their problems this week, but most of the kids will need to have numerous additional procedures over the years to take care of everything.  We have already identified the other experts we will bring in to continue their treatment next year.

One of the moms broke down in tears at the thought of the many years of operations and care that lie ahead, both for the cleft and for a serious gastrointestinal defect we discovered during the exam.  Our Nursing Director Loretta sat with her and just listened, reassuring her that she is not alone and that her beautiful daughter will be fine.  I called up to Candy, a social worker who has been with us for years.  She had finally gotten to sleep after traveling through the night to the mission, but she and her translator Pamela sprang out of bed to meet with the mom and help talk through her concerns.  Throughout the hotel courtyard, I noticed a change on the faces of the other volunteers as they felt the gravity of the conversation from a distance.  I think even though they did not hear the details being discussed, they were moved with compassion for this family, and felt assured that they were in the right place to make a difference for many others like them.  The surgeons developed a plan that gave the mom some reassurance, and scheduled her first procedure for Monday. 

The afternoon flew by as we met and planned and prepared for the week ahead when we will see over 1000 more patients.  Then just before dinner, a tired father with his 3-year-old boy, Leandro, came walking into the hotel courtyard.  The boy was decked out in a ballcap and sneakers just like the others, had a significant cleft palate like the others, but came from a different town more than 8 hours away.  We had seen him the week before, and scheduled him for surgery this Monday.  Although we had offered them lodging last week, they needed to return home for the weekend.  I was so pleased to see that they returned.  We gave them something to eat, and I had the pleasure of carrying Leandro on my shoulders as we walked them to their hotel.  Omar and Justin came with us, and helped describe the surgeons’ pre-op instructions. 

The poor boy was worn out, and we could hardly get a grin out of him on the walk.  But when we got to the hotel to check them in, a grey and white kitten rushed through the lobby, and Leandro pointed and squealed with laughter.  He laughed quite a lot like my 10-month-old Wyatt, who before I know it will be just as big as Leandro.  That laugh really moved my vantage point from an outsider trying to help into the perspective of his father.  When we finish this week, he will have traveled more than 32 hours in total, sacrificed several days of paid work with his family on the tightest of margins, and put his boy’s well-being in the hands of strangers just for the chance to make Leandro's life better.  I understood his motivation completely, but was humbled by his courage to make this all happen.  I pray that I can be such a good father to Wyatt. 

I’ve been doing this mission since 2003, but the feelings never repeat themselves.  As I change and as the community changes, my time in Ayacucho enriches me in more new ways than I could ever repay.