The Amazon Medical Project

March, 2010

            It is clear that our patients are just as enamored of the new clinic as I am. We have not only been seeing enough patients to make me feel that all the work was well worth it, but we have been having some Interesting Cases, too. I always explain to people that we doctors thrive on Interesting Cases, i.e., problems that are out of the ordinary. Like everyone in any line of work, most doctors see many of the same illnesses over and over (except the ones on television doctor shows, who have nothing but interesting cases). Thus, an unusual ailment or a perplexing problem is a welcome change of routine for us.

            From the patient’s point of view, however, one pretty much never wants to be an Interesting Case.

            There was a thirteen year old who passed out abruptly and was brought in by his family, who were terrified that he had suffered a seizure. It turned out, after careful questioning, that his faint had followed a vehement argument with his mother, his collapse occurring immediately after she had told him no, he was absolutely NOT going to go to Iquitos for the weekend.

            There was a fourteen year old who came in with a fever, three days after having given birth. If this were the pre-antibiotic era, she would likely have been one more victim of puerperal sepsis, in medical terminology, or “childbed fever,” for laypeople. Fortunately, we do have antibiotics, and she recovered handily (although she still has not come back yet for family planning, which has me worried).

            And the 22 year old whose brother-in-law came home drunk, started swinging his machete, and whacked our patient – twice – in the forehead. The victim had the presence of mind to defend himself with a chair, and managed to avoid being knocked out. But one of the lacerations actually cut into the bone, which suggests that if he had not been so vigilant, he could easily have been a victim of homicide rather than recipient of a few stitches.

            But the grand champion Interesting Case was the man from a village on the Napo River, who had tangled ten days earlier with a stingray. The rays of the river are nowhere near as large as the oceangoing variety; ours only get to be maybe fifteen to eighteen inches in diameter. But they have a very nasty sting, which takes weeks or even months to heal, and is very painful in the process. He had been seeing a local medicine man, but his family decided he was getting worse, not better, so they brought him to us.

            When this man arrived at the clinic, his family came up from their boat to ask to use the clinic stretcher, since he could not walk. They carried him in and maneuvered him onto the exam table. I noticed that he was grimacing painfully, and he said his abdomen really hurt. When I looked more closely at the man, his neck was so stiff that if you tried to lift up his head (which he did not want you to do, since it hurt), his whole body lifted off the table. His eyebrows were raised as if in surprise, and his entire mouth was forced into a strained smile, called rictus sardonicus in medical-ese. And he could not open his mouth at all, speaking through clenched teeth. His heart rate was rapid, his abdomen was so tense that his muscles stood out like a weight-lifter’s, and he was twitching frequently and complaining of cramps in his legs.

           Tetanus. Full-blown, genuine, lock-jawed tetanus, with a mortality rate overall of at least 50%. It was late in the afternoon, we could hear rain coming over the tops of the distant trees, and the pequi-pequi powered boat in which they had arrived was sputtering. Nonetheless, this man was likely to lose the ability to breathe, and/or to develop uncontrollable seizures, at any minute. We managed to get him to Iquitos, but when I went to the Hospital Regional on my next trip to Iquitos, his name was not on the list of ICU patients, nor could I find him on the medical floors. I finally located some nurses who remembered him, and they said he lasted eleven days before succumbing to the disease. Everybody, please, keep your tetanus booster shots up to date.

June, 2010

After going to Iquitos to run errands and get supplies, I had hoped to get back to the clinic early Friday afternoon, but did not arrive till 4:00. When I walked in, I found that little Elmer Melendez Murrieta, three years of age, had stepped on a cascavel an hour or so earlier. (Cascavel is a small member of the rattlesnake family, whose venom is thought to be much more potent than that of its larger relatives.) He must have really annoyed that snake, because he had reportedly been bitten not just once, but three times. Juvencio, Edemita, and Tiffany, our wonderful June volunteer, had taken a specimen of blood for clotting, and it didn’t clot at all. Furthermore, he was bleeding briskly from his gums. Then, just in case I was not yet worried, they reported that when he got to the clinic, his foot was pretty much normal except for three small puncture marks; but by the time I arrived, only one hour later, the entire foot was swollen and blue. They were trying to get an IV line in, but without much success. Fortunately, I was able to slide one into his antecubital vein, where they had drawn the clotting specimen earlier, and we got antivenin into him; but unpacking and tallying of purchases and medicines got pushed off till later.

And, the river is falling daily. Despite the torrential rains in Cuzco early in the year, this year’s annual flood was not much. The stream did not even get out of its banks at the clinic or at my house. Now, the water is dropping rapidly, and soon we will be walking across. For the moment, however, each day means negotiating a longer stretch of mud in order to reach my dugout, which I use to cross the stream to get to the clinic. The higher ground has dried out and is pretty firm, except when it rains (did I mention it has been raining a lot, lately?), and then the surface takes on the slick, slippery texture of wet potter’s clay. The farther down I go toward the stream, the softer is the mud … putty, then pudding, and finally slop. Golbert, who lives on the far side of the crossing, has been wonderful about putting out ever longer handrails and pieces of old lumber embedded in the muck to provide firmer footing. It is still quite a challenge, though. The other day, I successfully entered the canoe and pushed off from the bank, only to leave my paddle stuck in the mud as I floated gracefully, backwardly, across the stream. I used my hands to propel myself back and retrieve the paddle, but it was a bit of an operation, and I am sure that Golbert’s family has been deriving daily amusement from observing the gringa’s efforts to get into and out of her canoe. And we were off.