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Letters (Continued)

Continued from the previous page.

After several years of fewer and fewer snakebites, we have now had four so far this year. The latest was a man from Yanamono who, upon entering his house, picked up the machete he had left on the ground, and found a cascavel (basically, a rattlesnake) entangled with it. Fortunately, the bite seemed to be fairly mild, and when he came back for follow-up a few days later, he had virtually no pain, no swelling, no necrosis, no evidence of infection, and normal function in the finger. Interestingly, he reports this was the third poisonous snakebite he has received.

And, we now have a good clinic boat. As I mentioned in the last letter, I have waffled for years on the wisdom of having a boat, then we received a donated one and have used it periodically, primarily (almost exclusively) to transfer patients who require a higher level of care than we can provide. However, the donated boat was a lemon from the very beginning, and felt so unstable as to be downright dangerous.

Chambira

I therefore went to talk with a boat builder in Iquitos. Eventually we settled on a model incorporating a handrail on the front of the boat, a wide prow wide so we could enter the boat comfortably, with a handrail to help, a single transverse seat for the driver, a padded bench where a stretcher could rest, with a seat on the other side of the boat for clinic personnel and/or patient family, and extra thick aluminum for the hull of the boat. The initial estimate was S/10,000 for the boat, but moving the driver to the front raised that by S/3,500; running lights, in case we need to move at night or in poor visibility, added another S/1,500; and the extra thickness in the hull cost an additional S/1,500 (gee, this sounds just like buying a car … the "base" price turns out not to be the whole story). The final cost was S/16,500, or a little over $5,000. Meanwhile, Explorama’s boat manager took charge of our 40 hp Yamaha motor. He replaced the water cooling system, which was not running, confirmed that all the wiring and rings and other internal parts were in good shape, mounted a new propeller, and painted it all. It not only looks like a new motor, but it runs like one.

Once all was ready, we went to take the new boat out for its test drive. Miguel Cam, the owner of the facility, drove us to the port on the Rio Nanay at the edge of the city, and expertly maneuvered the long trailer backward down an uneven, gullied, flotsam-strewn hill (no paved launching ramps, here) to the edge of the water, dodging other vehicles, driftwood logs, and various pedestrians as he went. Once at the river, he and his crew enlisted the aid of neighboring boatmen, all of whom seemed to know him well, to push the crowded vessels aside far enough to back the new boat into the river. Miguel drove the boat, and, gently pushing boat after boat aside until there was a tiny opening large enough to allow us to pass, we backed into the river.

When Miguel opened the throttle, the boat practically leaped out of the water. I did not realize that a 40 hp motor could move us along at such a speed. But the boat felt level and stable, and as MIguel put it through various maneuvers, racing straight ahead, then twisting, turning, driving in a full 360 degree circle to the right, then to the left, it handled just like a boat should. Miguel had a proud grin on his face, and I felt as though we may finally have a boat that will serve us well.

October, 2017

When I left Peru, the river was low, and dropping further. Yanamono Stream, where the clinic, my house and the Lodge are all located, was too low for navigation even by a dugout canoe. All the boats, including our lovely new ambulance boat, had to park on the main river, and people walked in to the clinic, the Yagua village, and the Lodge. And, parking on the river was made more than normally inconvenient by the inauguration of a new ferry which runs from Iquitos to the border with Brazil, a distance of several hundred miles. It can carry a whole bunch of people, and I assume cargo as well, and makes the trip in a speedy eight hours or so.

The problem is, in order to move at this speed, the ferry boasts immense engines which churn waves up to four feet tall. All along the river, boats have been flung onto the shore, sunk, and/or had their motors damaged, and many floating docks have been destroyed, when the ferry passes. And it passes almost daily, going downriver on Tuesdays, Thursdays, and Saturdays, returning to Iquitos on Wednesdays, Fridays, and Sundays. Fortunately, it adheres very closely to its schedule, passing at predictable hours. Still, everyone who has a boat on the river, whether they live on the river or reside in a village inland (such as Las Palmeras), must trek to the edge of the Amazon each and every time the ferry passes, and take the boat out into the river to ride out the waves until the waters calm down again.

Complaints have of course been lodged, but the economics are against the river dwellers. The consortium which owns the ferry is wealthy, and apparently the government is subsidizing them heavily. This kind of power is not likely to respond any time soon to the problems of a whole bunch of people of modest means at best. So, everyone just has to live with it.

One Sunday, one of our neighbors, whom I had asked to come to look over the roof of the outdoor waiting area in front of the clinic, came instead with a bleeding foot. He had been cutting his firewood with an axe, and it had slipped, chopping into two of his toes. The lacerations were bleeding freely, but were no trouble to suture. But in cleaning him up, it was clear that he is a man of the rainforest, accustomed to walking barefoot. The soles of his feet were thick, tough, scored with dozens of tiny cracks, and clearly impervious to whatever he might walk on. Also, none too clean, though his wounds healed nicely.

Then, there was a 53 or maybe 60 year old man (he says he has lost his documents several times, and does not really know when he was born) who has been here before with rectal bleeding. He is an itinerant salesman, riding various boats up and down the river, selling a little of this and a little of that. He is also some form of evangelical, who wants only certain medicines and mostly thinks God and a few herbal remedies will take care of him, but confesses he has lapsed a bit lately, and suspects that is why this problem has returned to haunt him.

Tiny Frog in Hand

He reports that he has had rectal bleeding off and on for over twenty years. He is symptom-free for months, then the difficulty returns. He does not have pain with the bleeding, he has not been losing weight, he has had diarrhea every now and then, but did not currently have it, and it did not sound as though diarrhea is always associated with the bleeding. The blood is on the outside of his stools, not mixed into them, and he denies constipation or hard bowel movements. He drinks mostly bottled water, and last took worm medicine in July 2015. I saw him five years ago, first with diarrhea without blood, then a week later with bleeding not associated with diarrhea. His hematocrit at that time was normal (46%), and I recommended seeing a gastroenterologist. He says he did so, but the guy just prescribed ciprofloxacin and metronidazole, without doing any sort of physical exam. Or so he says.

His most recent visit to us before this day was a week earlier, when he saw Dr. Roldan with rectal bleeding and cramps, and received metronidazole for a three-day course of treatment. Roldan said he really did not think the man needed it, but he refused any physical exam, and insisted that metronidazole works for him, and nothing else does. Roldan strongly urged him to seek further evaluation in the city, but the man insists that as an evangelical, he simply does not believe in that sort of thing.

Today, he is back, wanting more metronidazole, because three days, he thinks, just was not a long enough course of treatment. I talked with him at great length, and tried very hard to get him to let us take a look at the area in question, but he absolutely refused. I explained that we were not going to prescribe medicines without having at least some idea of what we were treating, and furthermore explained in detail that his symptoms do not actually sound alarming. Given that they have been present off and on for many years, and he is not losing weight or having any other medical issues, he probably simply has hemorrhoids, which are a common cause of intermittent rectal bleeding. I told him I cannot rule out the possibility of cancer of the colon or rectum, and that evaluation by a gastroenterologist would really be a good idea. But he is insistent that he does not want modern medicine (except his beloved metronidazole), so we settled for a good long counseling session, and gave him his overdue tetanus vaccine. At least now he is unlikely to die from tetanus.

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