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Clinic Letters - January, 2019

On our first day open, following the annual clinic closure for Christmas, New Year’s, and inventory, one of our neighbors brought in her elderly uncle (“elderly” being probably in his late 60’s, though being a traditional person, he has no concrete idea of his actual age).  He was complaining of a rapid heart rate at night, intermittently, and sometimes trouble breathing when he lies down, and a little swelling in his ankles.  Listening to his chest, the diagnosis was easy – he has an irregularly irregular heart rate, which means atrial fibrillation.  We were handily able to confirm this with the new little bitty Kardia device I had brought back – just have him hold it in his hands, and hold it near a smartphone with the Kardia program, and there appears a neat tracing of his heart rhythm.  (An electrocardiogram shows twelve such tracings, each taken from a slightly different angle of view, which gives a better three-dimensional idea of the heart’s condition; but even one tracing is enough to diagnose atrial fibrillation.) 

Of course, making the diagnosis is one thing, doing something about it is another.  He did not really seem to be in congestive heart failure when we saw him, though Dr. Edward gave him a little diuretic just in case.  In the US, we would start him on anticoagulants, and send him for a cardiology evaluation and probably an ablation procedure.  Here, it would be foolhardy to put him on anticoagulants, if we could even find them in Iquitos – he would bleed from his stomach in no time at all.  And there are no interventional cardiologists in Iquitos.  So I explained the situation, and told him and his niece that this would just be something with which he would have to live.  Until he doesn’t, any more.  I see him on the path periodically, and he seems to be doing fine, for now. 

The next day, the woman who washes my laundry came to the clinic after having slipped, barefoot, on the river bank, fetching up against a piece of driftwood and ramming a goodly chunk of it into her great toe.  Dr. Edward pulled out a large splinter, about a centimeter in length, and very thick.  Nonetheless, she continued to complain of exquisite pain, despite the antibiotics he had given her.  She returned to the clinic five days later, and two days after that, and two days after that, and each time, she was limping badly, and her great toe was very, very tender, very red and hot, and swollen.  Finally, eight days after the original injury, with a digital block (anesthetic which numbed up the entire toe) and a little probing, I was able to touch something hard with the tip of a hemostat, and drew out another hunk of wood, this one maybe 15 mm. (5/8”) long, and a good 2 – 3 mm (1/8”) in diameter.  She was not crazy about the procedure while it was happening, but healed promptly once the wood was out of her toe, and is now walking normally and smiling again.

Operation

Jon Helstrom - Process


Her ten year old son also showed up, with a stiff, cartilaginous spine from a catfish lodged in his foot.  Edward removed it, all 5/8” of an inch of it.  Ouch. 

 A few days after that, a three year old was brought in from Capironal, a village a good two hours downriver from the clinic, with abdominal pain, a swollen belly, decreased appetite (though no vomiting), and two days without a bowel movement.  He did not have a fever, and was recovering from a bout of chicken pox.  He was obviously in a lot of pain, and any movement increased it.  Tapping on his heels made him writhe, flexing and turning his hip (either side) made him jump, palpating his abdomen anywhere got him to crying.  His lungs sounded clear, but he was breathing very rapidly, with a grunt at the end of each breath.  He actually had at least a few bowel sounds, but he seemed very suspicious for intestinal obstruction – volvulus, maybe, which is a loop of intestine twisted around on itself, or a bolus of worms, or intussusception, a condition in which the intestine sort of folds in on itself.  Any of these was beyond our diagnostic capabilities, let alone treatment (if he needed surgery) and besides, he looked sick, I mean seriously sick.  We therefore took him to the medical center upriver in Indiana, accompanied by his mom, to whom we gave a little money for food, medicines, etc.  His father returned to Capironal to take care of their other child.   Dr. Edward turned the boy over to the staff there, and came back to the clinic, hoping that the child would be transferred to Iquitos.  But you never know. 

A few weeks later, when I was in Iquitos, I went to the Emergency Room to see if I could track the boy down.  The staff in the pediatric emergency room were able to find the child’s name in their register.  The Indiana medical center had gotten him to Iquitos that night, and the ER staff agreed with the tentative diagnosis of intestinal obstruction. 

I then went up to the pediatrics floor.  The boy had been in the ICU first, then out on the regular floor, and had been discharged.  It took a while, but eventually I made contact with a nurse who told me that his final diagnosis was … meningitis, for heaven’s sake.  Even though he had no fever or stiff neck when we saw him, just the symptoms referable to his abdomen, apparently after a day or two in the ICU he developed a terrible headache.  A lumbar puncture was done, and he turned out to have bacterial meningitis (I asked whether it could have been viral, related to his chickenpox, but she was sure it was bacterial).  He had been treated with ceftriaxone, then oral antibiotics, and finally sent home. At last, a cure!! 

Edgardo in the Clinic Office

Since my dugout canoe has succumbed to the influences of time and weather, with cracks too large to either fill or mend, Orlando Murrieta agreed to build me a new one.  Jerry wanted to see how a genuine dugout is made, so Edemita’s husband Ari gamely agreed to take him to the work site.  Jerry was a bit concerned about getting into and out of Ari’s boat without falling into the water.  Unlike the Explorama boats, the local ones are smaller, tippier, and devoid of hand railings or other aids.  Furthermore, Edemita insists she warned me that they would be going well into the monte (jungle), but either I did not hear her, or did not understand, thus Jerry wore plastic sandals, not boots.  At any rate, Ari and Jerry dropped me off at the clinic, then dashed off in Ari’s boat to join Orlando. 

By 11:30, when clinic closes for the noon break, there was no sign of them, so someone else ferried me home.  Halfway there, we spotted Jerry and Ari, zooming toward us, both grinning ear to ear.  As we pulled closer, I could see mud streaked across Jerry’s shirt. 

Once back at the house, it became clear that the muck was not limited to his shirt.  His slide-on Crocs were slippery with it, his pants were filthy, there was mud on the bag I had given him to hold the camera and his hat, and he was generally a mess.  He explained that getting into and out of the boat had turned out to be the least of his problems.  They had traveled for half an hour up the stream to reach the work site, and once there, were confronted with a very steep, very muddy, very high bank.  To get up the slippery slope, Orlando went ahead and helped to pull Jerry up, and Ari came behind and pushed.  At the top, Jerry said there was a narrow, rough path.  This later narrowed further, then nearly disappeared, and both the local men hacked with machetes to carve a way through the forest. 

Arriving finally at the place where the work was in progress, there was a log which had earlier been felled and sliced in half horizontally.  On its now-flat top, Orlando had drawn a straight line down the center, then carefully measured lines on each side equidistant from the center, marking an oblong with pointed ends front and back.  He now stood on top of the log, and began hacking the wood away from outside the lines.  Jerry said his aim was highly accurate, hitting the precise spot where he wanted to strike, each and every time.  Over the next few hours, Orlando and Ari gradually trimmed away almost all of the surplus wood on one side of the canoe, and began the process of hollowing out the center.  

Then they headed home.  Getting down the muddy bank to the boat was as challenging as it had been getting up.  Ari cut a long pole, and Orlando scrambled to the bottom and planted one end of the pole in the mud.  Ari held up the other end.  The idea was that Jerry could use it as a makeshift railing, but he said what actually happened was that he slid down the slope, using the pole to keep himself from rolling and tumbling rather than sliding. 

So he had an adventure, and saw a dugout canoe in the process of becoming, and was as flushed with excitement as a little kid. 

A couple of weeks later, the finished product was delivered, and it is a beauty.  The wood is sturdy, dark reddish, with a good smell.  When I asked what wood it was, Orlando replied that it is anishirumi – just what I would have guessed.  Everyone nodded sagely and assured me that anishirumi is an excellent wood for a canoe, durable and strong.  It is not the lightest craft I have had, but it handles well, and is just about the right size, 4 ½ meters, and deep enough to accommodate my knees.  Jerry could sit easily in it, though it might be a little delicate if we were both in it at once.  (With two gringos, it would lie pretty low in the water.)  But for me, this is an excellent canoe.  

Also, I saw a porcupine!  I have seen these animals less than half a dozen times in all the years here.  This one was nestled between two of the stepping logs on the path to the clinic.  I stepped over him, noting that this was a fairly odd bit of vegetation, spikier than a breadfruit and not quite looking like any plant.  Then I took a closer look, and realized he was not a plant at all. 

He was about the size of both my fists together.  I suspect he was a young one, but as mentioned, these guys are seldom seen, and I have never seen one this close, and don’t know how large they grow.  He was huddled on the ground, with his head down, and every now and then, he would wipe his tiny adorable paw across his thoroughly cute little nose, downcasting his shiny black eyes.  I really wanted to pick him up and cuddle him, but figured neither of us would be happy with this, so I resisted the temptation.  I saw him again a couple of days later, and he was still just as cute.

February 2019

10 febrero, domingo (Sunday)

Rain came crashing down in torrents on the roof last night.  It would lighten up a bit, then resume with unabated energy, all night long.   My thatch roof is several years old and there is light coming through in several smallish spots.  In the middle of the night, I reached over to the far side of the bed, only to find Jerry’s pillow and the edge of the bed soaked, as water danced down from the largest of the bare spots in the thatch.  Nuts. 

Pulled the bed over a few inches, and hung the pillow to dry. 

11 febrero

Water beneath several of the boards on the walkway between my house and the Lodge.  I keep hoping the water, which has been rising ever so slowly, will drop.  But it does not seem to want to cooperate. 

12 febrero

Water over some of the boards, barely. 

13 febrero

Water an inch and a half deep over several of the boards, and over most of the floor of the path leading from the usual boat dock spot (though they have now moved the main dock to the area just outside the dining room) to the house where the watchmen keep watch, the former Bar Tahuampa.  I am still walking to meals, but carry Jerry’s walking stick to provide a little extra stabilization. 


14 febrero – Happy Valentine’s Day, Jerry!

Water ankle-deep over all the boards for the last twenty or thirty feet of the walkway, and covering all the ground under the thatch-roofed pathway to the bridge.  Needless to say, it is very slippery.  I walk to breakfast, but bring my canoe home for lunch.  My arms are tired, though the exercise will be good for my aging muscles. 

Alex Jose Tuesta

This is the first time since 2015 that I have had to resort to the canoe.  2016, ’17 and ’18 were pretty civilized, flood-wise, so I suppose I cannot complain.  But I am out of practice.  And this is only the second time ever in all my time here that the stream has gotten out of its banks in February. 

Back again to the flood – the river is rising steadily, but (at least so far, though that can change at any moment) slowly.  I sometimes feel guilty that we have so much water, when drought and fire ravage other parts of the world.  And I may whine about the annoyances of paddling to work and meals, but when the day is fine, gliding across the glassy surface of the water, rainforest and sky reflected as if in a giant mirror, with no noise save the dip and splash of the paddle, occasionally greeting one’s neighbors as we pass, I must admit, it is pretty picturesque.

 Bob Pelham -Hoatzin Bird

Dendrobatids

April 2019

 The river keeps on rising, still slowly, but still creeping up.  The clinic is now standing in water.  We’ve done this before, of course, and the floor is well above the water, and as long as the flood does not make a sudden surge, we should be able to continue operating.  The huatchimanes built a raised walkway from the boat dock to the front steps; and with any luck at all, the flood will peak soon.  For the first 20-some years I was in Peru, the annual floods reached their maximum stage in mid- to late May.  In 2012, when we set a new all-time high water level, the water crested in mid-April, and has done so in April ever since (don’t ask me why the water’s peak is earlier than it has historically been; I have no theories).  So hopefully, it will soon get as high as it is going to get this year, and begin to drop. 

All the same, everyone in the clinic is tired of being stranded in the middle of the water, and more than ready for the river to get back within its banks.  They do have a television, so they can watch the really important soccer games.  But there is no cell phone reception at the clinic itself – one must walk out to the edge of the river in order to get a signal.   With the path to the river underwater, this means they are even more cut off than usual from family and friends in the city. 

Of course, once the water retreats, there will be Mud Season, and that is to my way of thinking worse than the flood itself.  Depending on how deep the water rose over the land, and how long the land was flooded, the departure of the water leaves a layer of silty mud that can be as much as a foot deep, making walking a messy and sometimes difficult operation.  And the grass that lay beneath the waters is drowned, so until it grows back, there is no greenery in the areas that were under water, which gives a primordial look to the riverine landscape.  Fortunately, the plants do grow back pretty quickly. 

Late April –

The river is dropping, thank goodness.  When I get back in June, Mud Season should be over, and my feet will be clean and dry, and the grass might even be starting to grow back. 

Hurrah for Spring!

June 2019

Arrived home to Yanamono in mid-afternoon, after a wonderful couple of months in Wisconsin with Jerry, and immediately set about making my house into a home.  Ari and his crew had done a great job of cleaning.  The floors were newly swept and scrubbed, the sink and toilet and shower were sparkling, the shelves had been wiped down.  All I had to do was haul everything out of the boxes wherein it was all stored, and restore things to their rightful places.  By the time darkness seeped in, there were batteries in the various lanterns and flashlights, and the solar ones were in place to soak up the next day’s sun.  There was soap in the shower and sink, water for drinking and brushing teeth, my coffee cup set out for the morning, notepaper and pen on the bookshelf, batteries in the bedside clock, reading material on the bedside table, curtains in the windows, a few clothes hung in the closet, and the first batch of stored clothes set out for Lindomira to wash tomorrow.  The bed was made, and the papers and items that I brought from Wisconsin were sorted, with those destined for the clinic dropped into the clinic backpack, and the ones for here in their rightful places, and the red Lands End bag loaded for writing.  The hammock still needed to be hung, and my earrings hung in the screen, and of course there was all the clinic accounting awaiting my attention. 

Still, I was able to go to supper with Pam and Marie Trone, the dolphin lady (here studying the sounds the dolphins make) and the last night of the workshop for the local teachers, and come home to a clean, dry bed.  On the way to supper, there were gilded clouds, straight out of Raphael, piled up over Las Palmeras, blindingly golden. 

Coming back is always an exercise in being welcomed.  Hugs are given all around, and everyone greets me and makes me feel at home, and asks about “Don Jerry.”  The stream is back within its banks, and most of the worst of the mud has dried.  It’s like walking on an endless tray of brownies.  Traces of the silty muck are everywhere – there are deep footprints around my house where they replaced the walkway leading out to the path, and did the same for the bottom step.  The old walkway has been dismantled and used to make a platform beneath the faucet under the house, so I can wash off muddy feet, or rinse out the mop when I next scrub the front room floor.  On the path to the bridge and the Lodge, the silty mud has been scooped up and formed into dikes lining the path, and the dikes have hardened into place. 

Woke one morning just before six, to the sound of monkeys crashing about in the trees outside the casa.  Lots of monkeys.  By the time I got up to look, they were gone, but from the sheer numbers, and the fact that they did not talk to one another, I am sure they were frayles, the squirrel monkeys, who travel in large groups.  As soon as they had passed through, there was another troop, and I did not see them, either, but they had to be pichicos, saddle-backed tamarins, since they were very chatty, in their high-pitched, scolding way.  And not nearly as numerous as their predecessors. 

I felt pleased with myself, that I know this without even seeing the animals. 

Observed in Iquitos, on Condamine, a street whose surface is among the worst in the city: a camioneta, which is a sort of small truck (a motorcycle front end with a small covered trailer grafted on behind), with a cargo of eggs, bouncing along from one broken stretch of asphalt to another.  The eggs are packed in papier mache trays each holding a hundred eggs (ten by ten), which are then stacked ten high and bound with twine.  The stacks are in turn stacked two or three on top of each other, in three or four rows filling the entire back of the camioneta.  Each time the vehicle hit another crack in the road, the stacked eggs would fly up half an inch or so, hover for a scant moment, then settle back down, the stacks teetering slightly, only to levitate once more in a few seconds when the next jolt hit.  It seemed the possibility for disaster was high, since there was not much holding the whole cargo together except a flimsy piece of twine tied across the back of the camioneta, and a boy perched on the back gate, clinging to the roof with one hand and dancing lightly with his feet to help control the wayward eggs.  There was no mishap for the time that I had them in sight, though, so maybe the whole overloaded contraption made it to its destination intact. 

I am pleased to find that we now have some elderly neighbors.  In 1991 or 1992, I asked the local schoolteacher for a list of everyone in the Yagua village.  Among 122 residents, there were only six or seven people in their 50’s, none in their 60’s, and one who thought he was 70 years old.  Now, there are multiple older folks, and they are starting to run into the same problems that affect us all as we age.  One of these men, who is thought to be in his late 80’s, was brought in by his son after becoming dizzy and falling, bashing his ear and causing a large bruise there.    Unfortunately, at that age, once you begin falling down, you are headed for trouble, and there is little that can be done to prevent the dizziness that leads to the falling.  Exercises to improve strength and balance would be prescribed in developed countries, and devices to help around the house, and so on.  But here, with uneven surfaces everywhere, mud everywhere, no physical therapists within reach, and no indoor plumbing (means he bathes every day in the river), about all I could do was warn him and his son to be as careful as possible.

July 2020

Woke this morning to our first frio (cold spell) of the season.  There was rain all night (again), and in the morning there was some breeze, and with it came the cold air from Antarctica.  This does not seem to be a super-strong cold front (though we hear it is quite a bit cooler in Lima), but it is a frio, all right.  I wore a long-sleeve shirt to clinic this morning, and in the afternoon put on my only jacket.  Tonight, I will sleep in a long-sleeve shirt, beneath the sheet, bedspread, my warm fuzzy shawl, and an extra sheet spread over the top of everything just for good measure. 

Paradoxically, today is the day to take a shower.  The water in the big holding tank still retains yesterday’s heat, and is thus warmer than the air.  By tomorrow, it will have cooled to the current air temperature, and bathing will be a chilly process for the next few days, until the cold passes and we return to our usual tropical warmth and sunshine. 

I was hearing a lot of small crashing sounds in the trees behind my casa, and initially I thought it might be more monkeys.  But the sounds were more or less continuous, at night as well as in the daytime hours, and I don’t think the monkeys are nocturnal.  Also, monkeys leap from branch to branch, so there is a characteristic sound of the branches swinging back up after having been relieved of their weight, and that sound was not there.  This was just something falling through the greenery straight down to the ground. 

Young Boy on Examination Table

Then I remembered it’s aguaje season.  Aguaje is a palm which has an edible fruit which is highly prized around here.  The fruit is roughly the size and shape of a chicken egg, with a surface covered in dark auburn scales.  You soak the fruits for a while in warm water, then scrape off the scales with your teeth to reach a thin layer of yellow palm fruit beneath.  The flavor is not like anything I’ve ever had outside of Peru, but it’s tasty. 

Sure enough, the two or three trees behind the house must have been absolutely loaded with fruit, and these were leaping free, day and night.  One morning I had Rocky over to polish the brass door knobs and plates, and he brought his daughter, now eight, with him.  I was impressed that a child of that age was able to sit still in a chair for long periods of time while her father rubbed and scrubbed at the brass.  Still, she did need to move around some, so I suggested she collect some aguaje to take home, and gave her a large bag.  Before long, she had gathered nearly a bushel of them, and since then, everyone else has been rummaging around out in back, collecting them in quantity. 

August 2020

I think that Edemita thinks I am reasonably smart when it comes to being a doctor.  But she is thoroughly convinced that I am dumber than a rock, regarding certain other things. 

One afternoon, as I was heading back to the clinic after lunch, I nearly collided with a snake.  He was about to cross the wooden pathway just a short step in front of me, when we each realized the other was there, and both beat a hasty retreat.  I quickly stepped back three or four paces, while the snake pulled off the walkway and executed a fancy turn which left his tail twisted into a neat curve.  He was about half a meter long, about as thick as my thumb, was black with red and white and orange vertical stripes, and had a rounded head.  When he flipped his tail end around, he revealed a large, bright orange patch.  I wasn’t sure exactly what it was supposed to represent, but it was clearly a threat mechanism.  I was pretty sure he was a naca-naca, a coral snake, so I did not want to get too close.  I did pull the camera out of my backpack, though, and took a photo or two. 

Then there was the question of what to do next.  I tapped my paddle gently in his direction, but instead of turning toward the forest, he headed back toward the house.  Hmm.  I would prefer that he not do that.  I tapped again, and he again executed the quick flip and displayed the orange blob.  After holding the pose a moment or two, he resumed his trek toward the house.  I tried several more times to dissuade him, but he was just getting more agitated, and I did not want him to make a sudden attack at me, so finally I gave up.  He beat a speedy retreat to the shelter of the board platform by the faucet beneath the house, where I can wash off my muddy feet, and dove under the platform, where I am sure he hoped that this malevolent giant armed with a huge wooden club could not reach him.  I was not about to pursue him under the boards, so I gave up and headed for the clinic, hoping that he would not decide in my absence to further explore the house but would instead return to the safety of the trees. 

When I got to the clinic, I related the adventure, and showed the photo to Elmer and Edemita.  They agreed it was a coral snake, and Elmer said that tail-twisting movement was characteristic of the naca-nacas.  Edemita just rolled her eyes, shook her head, and said, why didn’t you just kill it, doctora?  (as any sane person would have done, she refrained from adding, but it was clear she thought I was nuts to have missed the opportunity).

There are various forms by which I am addressed in Peru: at the clinic and Lodge, I am almost always “Doctora,” though a few people actually know my name, and one of the guides habitually calls me “Doña.” In the city, I am, variously, amiga (friend), Señora (Mrs., or Ma’m), Señorita (Miss), bonita, linda (both synonyms for “pretty” – similar to being addressed as “honey” in the South), hermana or Madre (an older gringa in a skirt, without make-up, must perforce be associated with some religious order), or, occasionally, my personal favorite, “reina,” (which means queen).
Horario

November 2020

Oh my, we are coming to the end of yet another year.  Around this time last year, I wrote that I was considering downsizing my time at the Clinica Yanamono, so it is time to update that subject. 

When I first began working in Peru, I spent most of my time here.  I was in the country throughout the 1990’s, save for occasional forays back to Wisconsin, family, and friends.  By 2001, I had arrived at the verge of burnout, and also recognized that I had better begin thinking about getting old and perhaps, some day, even retiring. 

I therefore began spending about six months per year in each country, adding a Peruvian physician to our staff so the clinic could remain open whether I was on-site or not, and taking on part-time work at emergency rooms in Wisconsin in order to earn more money than I could by working in the rainforest.  At that time, a number of clinic friends and supporters expressed the thought that I would probably gradually increase the time spent in Wisconsin, and decrease that spent in Peru, until I was fully retired.  That hasn’t happened yet. 

Still, especially since meeting Jerry (in 2005, my goodness, the time does fly), I have fudged a little, leaving Peru just a little early, returning from Wisconsin just a little late.  In the last fifteen years or so, I have been spending a total of roughly five and a half months of each year in Peru, and the remaining six and a half months in Wisconsin. 

This year, I spent less time at the clinic than in any year since I began coming to Peru in 1990.   Nonetheless, I spent about four and a half months in all in Peru, and remain fully involved with the clinic, both in Peru and while in the U.S., where I am now receiving monthly statistical reports which are being scanned and sent to me, which means I can be keep up better with what is going on.  (This also means there will be less work for me to do when I return in January.)  After last year’s letter, a number of people wrote to encourage me, a few wrote to say they are going to take the Amazon Medical Project off their list, and one wrote to say I am either going to have to bow out, or stay forever.  I am terrible at predicting the future, but probably, “stay forever” is the closest … though staying may be defined a little differently than it has in past years. 

A U.S.-based non-profit would, I think, represent the best option for continuing the clinic once I expire, since there are no Peruvian non-profits that are likely to be able to generate the funding needed to keep the clinic going, and I have often mentioned the shortcomings of the Peruvian health system.   I have spoken through the year with a couple of U.S.-based groups who might conceivably want to take the clinic over, if ever I leave, but so far, nothing concrete has developed.   Then again, you never know what might turn up. 

So, at the moment, we are continuing pretty much as we have for the last few years.  I am, as I mentioned, stretching my time in Wisconsin a bit more, but am still intimately connected to the clinic, and at this point, it seems likely that this pattern will hold for at least a few more years. 

If anything changes drastically, I’ll let you know.