BRINGING VSI IMAGING to the AMAZON of PERU (Chapter 5)

Another travel day starts brutally early as the alarm sounds at 5:40 am – I’m sure I am not the only one who hates alarms.  Thankfully, packing was brief since we did not take out any equipment for our one-day stay in Iquitos.  I had no idea what to expect for the day, other than we were starting off on an Amazon tributary (the Rio Itaya), then 20+ miles up-river on the Amazon, followed by a meandering 100+ miles up-river on the Rio Napo to Santa Clotilde.

Arriving at the docks, we paid local porters to bring our baggage down.  We weaved through alleyways and down steps to find ourselves in front of some warehouse-type building with ramps and a partially submerged, wobbly board that took us across in front of our boat.  As we waited to board, we were presented with a quiet sunrise over the river.

The boat operators loaded our luggage on the boat roof.  We were met at the dock by Gabriela Filonowicz and Dr. Norberto Aramburu, who were traveling back to Santa Clotilde. Dr. Aramburu is from Spain, but has been working at Santa Clotilde hospital for two years.  Three of his old college mates had flown out to meet him and I guess see what life was like, practicing medicine in the jungle.  We started off the trip comfortably enough.

We were told this first leg was only about one hour and that we would be stopping at a town called Mazán, where we would disembark, take moto-taxis across a two-mile strip of land, and reboard a different boat for an additional 7 hour journey up the Rio Napo.  As seen in this map, the Napo does flow into the Amazon, but the junction is further down-river and would require an extra loop, likely adding a few hours or so to the total travel time.

On the boat, Brian and Leslie bought fans from an enterprising vendor who came aboard for sales.  I sat with Gabriela and listened to a little of her background. She is a Catholic lay missionary from Poland.  She started off working in southeastern Africa, and then northern Peru.  She has been in mission work for twenty years.  In Peru, she started out working with children in Iquitos.  If I heard correctly (recall it is a noisy boat and my Spanish is only mediocre at best), she had worked there for nearly fifteen years.  Every two years, she goes back to Poland to meet with the Diocesan Bishop to renew her assignment.  She told me this has worked out very well, as it provides her the opportunity to request what she needs to help the people.  A few years back, the opportunity came up to help run the hospital at Santa Clotilde.

To capably administer this job, Gabriela took classes in management.  It was evident that she is very bright and has a winsome personality.  All of the taxi drivers, porters, and boat drivers know her and show obvious respect.  I found it particularly impressive that they found a way to make happen whatever she asks of them.  This was very encouraging, because for a project to be successful you need the right partners.  You can have amazing technology, a dedicated team, and the best intentions, but without someone in the local region who has the appropriate clout and serves as the project’s champion, it will not succeed.  We are very fortunate to have Gabriela.  She understands how the project can help people, and she seems committed to making this a success.

We had to disembark at Mazán and as you can see, this entails walking a gangplank.  By now, it was very warm and sunny as we waited on the river bank for our luggage to come off the boat roof and load into moto-taxis for the short ride over to the Rio Napo.

While awaiting the next departure, we walked into town where we bought egg sandwiches and water.  I am including some pictures to give you a sense of what the market is like.  (For all of my Massachusetts die-hard fans) you may notice a backpack with the Boston Celtics’ logo for sale – even here in the Amazon jungle. You can also see a moto-taxi with some chickens hanging in the back.

We boarded the boat last – this was a mistake!

Every seat was taken except for three in the back.  The very back seat was isolated and right next to the bathroom.  I did not want Leslie to get stuck with this seat, so I offered to take it myself.  The first problem became evident as soon as I sat down.  The seat started to rock and tip over because it was not anchored to the floor.  There was a 5-gallon plastic bucket next to the seat which I used for lateral stability – and then by spreading my legs wide, I kept the seat, for the most part, from tipping over.  The next issue became apparent when the boat started to move.  It did not have a complete set of windows above the gunwale to protect passengers from water spraying up the side into the passenger compartment.  This condition was exaggerated by the back of the boat resting the lowest.  To make the situation more comical, a tire tied to the side, used for docking the boat, was slapping back and forth with the waves, causing torrents of water to splash up, drenching my right arm and leg.  Eventually, I was able to fix this problem by stuffing a couple of life jackets into the missing window’s opening, thereafter only getting the occasional dousing when a wave was particularly aggressive.  The third and final issue was the noise.  I was virtually sitting on top of the boat motor.  The sound was deafening.  This problem is exacerbated by the fact that ever since I had Covid, I suffer from hyperacusis – a lovely condition which results in sounds being amplified in your head.   After the first hour, I dug through my bag to find a pair of foam earplugs.  This helped, but not enough.  Finally, I decided to get out my noise canceling headphones because I was sure to go crazy from the noise and resulting headache.

By the time we arrived, I thought my feeling queasy was the result of the ride.  I’m sure it did not help – but that was not all of it.  As we walked up the stairs to the hospital and our living quarters, I knew I was sick, with clear fever symptoms.  This is my tenth “mission” type trip and I had never before succumbed to illness.  I am very careful, trying to avoid the obvious pitfalls – but apparently, I was not careful enough.  Feeling lousy, I did not take very many pictures after landing, the walk up to the base of the clinic, or the long stairs that go up to the boarding house where we were staying.  I did capture a picture of the ambulance they use at the hospital.  In this case, the patients were our suitcases, sparing us having to carry them up the hill.

When we got to our quarters, I lay down in bed and skipped the afternoon meetings.  I just lay there and tried to recuperate.  I’d likely picked up some bacterial infection and was now going to experience its power.  Ironic how we can be laid low by something so small.  The rest of the day was a blur.  The little personal fan was my redemption.  I don’t know how I would have survived without it.   I was given an antibiotic and some Tylenol and eventually became well enough that I could try to eat a few bites.

This experience reminded me about the value of unexpected kindness and compassion.  One of the Sisters, Yanabel, of a religious Order called Las Hijas de San Camilo (the Daughters of Saint Camillus), known by a large red cross that is sewn onto their habits, heard I was ill.  She went off to make chicken soup for me and then proceeded to brew up some chamomile tea.  She was so kind and sweet, trying to make sure that I was taken care of.  She works the dayshift as a nurse, and could easily have said after a full day’s labor, that she was tired and had already done what was required of her.  Instead, she showed concern for a stranger she had never met.  There are angels in this world.  I am sorry that I did not get a picture of her – but I guess my synapses weren’t firing well at the time.

Again, I am thankful for everyone who is following this journey with me. Look for my next chapter soon.  Below are hyperlinks to the prior blogs on Bringing VSI Imaging to the Amazon of Peru:

Bringing VSI imaging to the Amazon of Peru
BRINGING VSI IMAGING to the AMAZON of PERU (Chapter 2)
BRINGING VSI IMAGING to the AMAZON of PERU (Chapter 3)

Frank Miele, MSEE , President of Pegasus Lectures, Inc. Frank graduated cum laude from Dartmouth College with a triple major in physics, mathematics, and engineering. While at Dartmouth, he was a Proctor Scholar and received citations for academic excellence in comparative literature, atomic physics and quantum mechanics, and real analysis. Frank was a research and design engineer and project leader, designing ultrasound equipment and electronics for more than ten years at Hewlett Packard Company. As a designer of ultrasound, he has lectured across the country to sonographers, physicians, engineers and students on myriad topics.

BRINGING VSI IMAGING to the AMAZON of PERU (Chapter 4)

Not sure anyone really enjoys early-morning flights, especially when they allow for only four hours of sleep.  Today we flew to Iquitos , the capital of Peru’s northernmost region (Loreto), which incorporates their equatorial forests.  We are meeting administration at Hospital Regional De Loreto \”Felipe Santiago Arriola Iglesias\”, a few doctors within their staff, and an official with the Ministry of Health of Peru (MINSA) to outline our initiative and goals.

Our purpose in meeting was to persuade the hospital administration and staff to participate in a correlative study, similar to those conducted in our prior mission in Uganda.  In Uganda, we completed a “Concordance Study” and an “Outcome Study.”  The concordance study is a comparative assessment of VSI sweeps against conventional ultrasound evaluations.  In this study, we would need both “normal” and “abnormal” patient surveys to validate the VSI protocols and process.  For the outcomes study, we would need to access post-procedure patient data to evaluate VSI’s efficacy.

At the airport, we received an impromptu cardiac stress-test when baggage check-in flagged some of our luggage as over-weight.  Despite our frantic efforts to reapportion the suitcases, mixing out clothing, the ultrasound system, the UPS (backup power supply), gallons of gel, video capture devices, MIT boxes, various cables, and personal items, we still ended up with one over-weight bag.  Airport staff redirected us to the opposite end of the terminal to pay an added fee, lacking the commerce equipment to take payment right there.  Our flight was nearing departure as we stood in line to make payment, but mercifully a kind-hearted supervisor, perceiving our distress, waived the fee so that we could get going.  We made our flight with five minutes to spare.

Rushing back through, I noted a sign: “Comienza Aquí”, which seemed perfect as an obvious metaphor for the journey on which we were embarking.

With the moments we had to spare, we grabbed a sandwich at the little store in front of our gate – and boarded the plane to Iquitos.
When we landed, we disembarked onto the tarmac. I felt like reciting the line from the Wizard of OZ – “I\’ve a feeling we\’re not in Kansas anymore.”

There was great excitement and relief when we saw our side-tracked, over-weight bag on the luggage carousel, as we had left it marooned, across the airport from our departure gate.  We were not sure that bag would make it!

From the airport, we took a car over to the hotel to drop off our luggage.  (You can see a picture of the front door and also the view from my room) in the associated pics.)  It was, not surprisingly, very warm and humid.  The roads are congested with what are called moto-taxis, which are basically motorcycles with the back wheel removed and instead attached to the axle of a two-wheel cart behind.  They make a fair amount of noise and the drivers seem fearless as they dart in and out of traffic.  From the hotel, we took our trip to Hospital Regional De Loreto in a moto-taxi (an experience everyone should have at least
once).

Upon our arrival, we were welcomed by Gabriella, the Santa Clotilde hospital’s administrator, and Dr. Norberto, from its hospital staff.  As I referenced in my Introductory blog, our journey would tomorrow continue by 8+ hour boat ride to Santa Clotilde, and then another 8-hour boat-trip up the Rio Napo to the rural village of Angoteros.  This was our first meeting with Gabriella in a non-Zoom conference setting.  You will hear a lot more about Gabriella in the upcoming blogs.  She is an effective and dynamic powerhouse with an obvious ability to make things happen.

We later met Alex, the Hospital Regional De Loreto’s administrator.  Once we began our presentation, it became very clear that Alex was excited about what he was hearing.  His enthusiasm was encouraging and uplifting.  Charlie, the MINSA official arrived a short time later.  He also very quickly grasped the benefits our program could offer.

Our discussion expanded to an explanation of the logistical challenges specific to Iquitos and the region of Loreto.  Iquitos is bounded on three sides by the Amazon and two tributaries, the Rio Nanay and the Rio Itaya .  Consequently, Iquitos is functionally more like an island than a connected land mass.  Transportation to and from Iquitos is by air or by river transport.  In the Loreto region, many places have access only by river or by foot.  So, when someone becomes ill in the remote areas of the region, it is extremely challenging to get them to Iquitos or Santa Clotilde where they can be treated.

Transportation of the sickest patients is done by water taxis, or in extreme cases, by sea planes that can take off and land on the rivers.  Because of the expense, potential patients will often wait until their condition is so grave that they cannot be treated successfully or cured.

Another efficiency concern surrounds when patients are flown in for a condition that causes pain but is not life threatening (like a cyst).  The possibility of reducing these unnecessary flights seemed to excite Charlie, because if they could reduce unneeded transportation costs, these funds could be used elsewhere.

In the picture below, my left hand is pointing at Iquitos.  My right hand shows how far up the Rio Napo we need to travel to Santa Clotilde.  Brian’s left hand is pointing at the village of Angoteros.  You can see how close we will be to the border of Ecuador.  It sure looks like a long trip.  You are probably asking – “Why are we smiling?”

As we left, Alex suggested that we could meet with some of the Hospital Regional De Loreto’s doctors after returning from our training sessions in Angoteros and Santa Clotilde.  We had accomplished our first goal and were very pleased.  Success on the first of many phases.  By the way, did I mention that the room was air conditioned? – it felt like heaven.

We took another moto -taxi back to the hotel.  Each of us had work to take care of so we spent the next few hours on our laptops – aided by the fact that we had internet access.  We walked to dinner around 7:30 pm, after which we saw the hotspots of Iquitos.  Along the Rio Itaya, there are many restaurants, dance clubs, bars, and ice cream shops.  Throngs of people were out in the very humid air, enjoying the start to the weekend.  Young people were dressed up and obviously involved in their courting rituals.  The place was very alive.

We headed back to the hotel, knowing that we had an early morning to get to the boats to travel nearly eight hours to Santa Clotilde.

Below are hyperlinks to the prior blogs on Bringing VSI Imaging to the Amazon of Peru:

Bringing VSI imaging to the Amazon of Peru
BRINGING VSI IMAGING to the AMAZON of PERU (Chapter 2)
BRINGING VSI IMAGING to the AMAZON of PERU (Chapter 3)

Frank Miele, MSEE , President of Pegasus Lectures, Inc. Frank graduated cum laude from Dartmouth College with a triple major in physics, mathematics, and engineering. While at Dartmouth, he was a Proctor Scholar and received citations for academic excellence in comparative literature, atomic physics and quantum mechanics, and real analysis. Frank was a research and design engineer and project leader, designing ultrasound equipment and electronics for more than ten years at Hewlett Packard Company. As a designer of ultrasound, he has lectured across the country to sonographers, physicians, engineers and students on myriad topics.

BRINGING VSI IMAGING to the AMAZON of PERU (Chapter 3)

Where we last left off, the MIMAs team had arrived in Lima, hoping to enjoy somewhat of a “Consolidation” day, before a next-day, early-morning flight to the city of Iquitos, the capital of the Maynas Province within Peru’s Loreto Region (its northernmost).

The day started early – 6:00 am. I got up, checked emails and then headed down to the Mercure hotel’s small gym. After sitting on a plane so long yesterday, it felt good to get in a workout. I have included a picture of myself in the gym. Yes – I looked tired. I must admit – I did not enjoy taking the selfie and I believe no others will be forthcoming.

Once finished at the gym, I headed down to breakfast to meet my fellow travelers Brian (MIMAs founder, Dr. Garra), Ben (Benjamin Castaneda, PhD), and Leslie Trujillo. Ben is a professor in biomedical engineering at Pontifical Catholic University of Peru (PUCP) and a MIMAs board member. Leslie also works for PUCP in a business role, as well as working as the administrator (and the person who makes everything happen) for MIMAs. I had not seen them, other than by online chats, since just before the pandemic hit three years ago.

The included hotel breakfast was very good. I had another lesson in humility this morning when the waitress tried to ask me questions which I was incapable of understanding. I don’t know if this was the result of accent, speed, or both – but I simply could not make out what she was saying. She was very patient and very nice, ultimately using the universal language of gesticulating, resulting in a platter of fried eggs and fresh fruit.

Ben arrived first, and we picked up right where we had left off years ago in person. Brian arrived shortly after Ben. Although he had landed at 1:00 am and gotten less than four hours sleep, Brian was ready to go. Leslie arrived later, after finishing another meeting covering our future logistics that ran long.

Our “reunion” breakfast was cut short, because the transportation arrived early. We had scheduled a morning meeting with a company with which MIMAs had partnered, Medical Innovation Technologies (MIT).

Now is probably a good time to explain the role of Medical Innovation Technologies in our venture. Dr. Garra’s Volume Scanning Imaging (VSI) protocols were pioneered in 2007. These were tested in rural Vermont, then in the Central-American nation of Belize, and deployed into the field for the first time in Uganda in 2011. I participated in these initial deployments with a group called Imaging the World (ITW).

The methodology involved input of the VSI ultrasound images into a laptop with specialized software to organize and compress the sweeps before transmitting the cases to a PAC system through cellular data uploads. This process required some degree of knowledge from the user to start the laptop, open the program, and assure connection to a cellular network. When the studies did not transmit successfully, the user might have to take additional steps. The process worked, but required more training and added a layer of complication. This is where Medical Innovation Technologies in Peru came in.

As a company, they liked the idea of VSI scanning and saw how this approach could be used to facilitate a wider use of ultrasound scanning throughout the country. They embarked on creating a “medical box” to take over all of the tasks of the laptop and software, including the case export capability. They also added some tutorial functionality onto the platform in addition to developing a cloud service for importing the cases, assigning the reading, creating the interpretation and sending the results back to the clinic. Their system improved much of the reporting that was being done previously on paper, and/or transmitted back to the clinics via SMS texts.

Our meeting at Medical Innovation Technologies went well – and at the conclusion we carried away the two (“medical box”) systems which we would bring to the villages in Peru’s northeastern Amazon. Everything was going on time and as planned, so we headed out to lunch. We shared a few very tasty Peruvian meals and headed back to work. This is when the day went from the expected to the unexpected.

As we initialized the ultrasound system, an error-warning flashed (in Spanish) that related to the device’s air filtration and cooling. With less than 24 hours before our early-morning flight to Iquitos, there was no time to have repair or maintenance performed on the machine. Our options being limited, yet knowing my engineering background – it was decided that I should attempt to take apart the system and see if the cooling fans were the cause of the error-warning. Once we found tools and got the system apart, on boot up, I noticed that one of the little DC box fans was stuttering. Now began the scavenger hunt. We went to multiple stores and could not find a replacement fan. Spending this unexpected time meant we were now behind schedule on everything else – and we were no closer to having a working system. Keep in mind that this equipment will be used in the Amazon, so having a system with a dead fan is not really a great option.

After many hours, we gathered together images of the part and specs which Leslie sent to her brother who lives closer to the heart of Lima’s downtown – about an hour travel in traffic away, where electronic markets exist. He found a fan that met the specs after a few hours of searching, but its connector was not compatible. This meant that we could have to cut off the connector and solder wires together. So at those same markets he had to purchase a soldering iron and solder – as we, of course, did not bring that with us.

While we waited for the parts to arrive, we determined another suitcase would be needed to fit all the electronics and training materials. Off to the stores with a tape measure, in search of an affordable suitcase, we went. Unfortunately, by this time it was 9:30 pm. After a walking about Miraflores and near John F. Kennedy Park (sometimes referred to as El Parque De Los Gatos – because of the number of cats) we found a suitable suitcase. We could now finally get dinner while waiting for the parts to arrive. The group decided to return to the restaurant where I ate last night and dinner began at 10:30 pm.

There we met up with Lorena, another MIMAs board member who currently works for the United Nations. At least we had some great food as you can see – some closeup pics of the food are included for the epicureans amongst you.

At midnight the fan was installed and worked –a huge relief for Brian and me. We got back to the hotel at 12:30 am, with the plan to be out by 7:30 the next morning (with suitcases packed) ready to head to the airport.

Thank you for sharing this journey with me. Look for my next installment soon. Below are hyperlinks to the prior blogs on Bringing VSI imaging to the Amazon of Peru:

Bringing VSI imaging to the Amazon of Peru

BRINGING VSI IMAGING to the AMAZON of PERU (Chapter 2)

Frank Miele, MSEE , President of Pegasus Lectures, Inc. Frank graduated cum laude from Dartmouth College with a triple major in physics, mathematics, and engineering. While at Dartmouth, he was a Proctor Scholar and received citations for academic excellence in comparative literature, atomic physics and quantum mechanics, and real analysis. Frank was a research and design engineer and project leader, designing ultrasound equipment and electronics for more than ten years at Hewlett Packard Company. As a designer of ultrasound, he has lectured across the country to sonographers, physicians, engineers and students on myriad topics.