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Letters (Continued)

Continued from the previous page.

January, 2018

When I wanted to head back downriver to the clinic, there were no tourists going that way.  There is, however, the carguero, the large boat which carries assorted supplies for Explorama’s lodges from Iquitos to Ceiba Tops.  I could catch a boat to Ceiba and spend the night there, then early the next morning, join the small boat sent by the Lodge to collect its share of the cargo. 

It rained that night, and the morning dawned gray and promising more moisture.  I had morning coffee, ate breakfast with the employees (too early for tourist breakfast to be ready yet, and besides the morning pango, broth with herbs and chicken and boiled plantain, was delicious), then collected my belongings and walked down to the boat dock.  I could see the heavy wooden cargo boat in the middle of the river, just turning and pulling into the landing, so my timing was good. 

Exam


This boat has wooden hull, flooring, sides, and roof, with metal cladding on the top of the flat roof, where several molded plastic canoes rested, awaiting transfer to a group staying out at the Napo Lodge.  Inside, it is about ten feet/three meters across, and probably 60 feet/20 meters in length.  It arrives packed with linens, drinking water, tools, food, and everything else necessary to keep tourists accommodated in the rainforest. 

There was a boy who appeared to be about seven years of age who was there helping his father to unload the cargo.  The boat pulled in to a small dock, with wooden steps angling up the steep bank.  At the top of the bank there was a wooden walkway.  The boy darted down the steps to the dock, quickly sized up the cargo piling up there, seized a package of table napkins practically as large as he was and lifted it onto his skinny shoulder, then trotted quickly up the steps, grinning as he did so.  He returned and got another bulky package of toilet paper, then came back for more.   His dad came bounding up the steps with a rack of bananas in each hand.  After he went down, I lifted one, and could barely do so.  If I tried to carry two, I would be walking very slowly, and doubt I could have come up the steps with them at all, much less at double time as he did. 

The son was clearly proud to be working alongside his father, and eager to demonstrate his usefulness.  He lifted a bundle of bleach bottles shrink-wrapped on a cardboard pallet onto his shoulder, then picked up another one in his free hand.  Up the steps he went, depositing his load onto the wooden walkway, then down again for more.  He was expert at judging what he could not carry.  He tentatively hoisted a couple of boxes and decided they were beyond him, and when he looked at a case of beer, he glanced toward his father, who indicated that he should leave that alone and instead piled the boy with a couple of smaller boxes. 

Cargo kept coming up out of the boat's hold -- cases of canned milk, large cloth bags filled with bed linens, plastic crates of squash, beans, cilantro, mangos, garlic, potatoes, packages of pasta, tomatoes and heads of cabbage, tins and jars of coffee, boxes of tea, pallets of bags filled with sugar, sacks of rice, cases of soda pop and beer and wine, bags with frozen chicken and fish and beef, two liter bottles and five gallon carboys of drinking water, bags of laundry detergent, heavy metal tanks of liquid propane for the stoves, tools and implements and insecticide and oil.  It was all handed out to the man unloading it onto the dock and quickly hauled up the wooden stairs to the walkway. 

After a while, it began to rain, barely a mist at first, then more definitively.  The river's surface became choppy and the waves were pocked with millions of droplets falling straight down from the sky.  There was no wind, so the rain fell in straight lines, many of them.  The boat was close to being emptied, and the rain was becoming more persistent.   I had donned a rain poncho, and covered my bags with an old one, but Altomiro invited me to shelter inside the boat as we sorted out what was to go to Yanamono and waited for the rain to abate.  The boy and his father sat in the boat for a rest, and the lad danced in the entrance to the boat, accompanied by music from the blaring radio.  Everyone laughed appreciatively, and he smiled shyly.  The enticing aroma of mangoes and the fragrance of cilantro filled the boat.  

Among our first patients were an older couple with a regular laundry list of problems.  The woman, in her late 60's, had a cough for three months, had been losing weight, and was very pale.  The couple were drinking river water without boiling or chlorinating it, as they had done for decades, and had not taken worm medicine for who knows how long.  They lived far down a river on the other side of the Amazon.  They said they had gone both to the local medical post, but no medicines had been prescribed, and according to their daughter and son-in-law, not much had been done. 

Her husband, in his 80's, had trouble urinating, was also quite pallid, and had aching joints pretty much everywhere. 

Whenever anyone in a developing country has a chronic cough, the first thing to rule out is tuberculosis.  On physical exam, the woman had no lumpy lymph nodes above her collarbone, where there often are swollen glands when tuberculosis is in the lungs.  As noted above, she was very pale, and her hematocrit (the percentage of her blood which was actually red blood cells) was just 28%, a moderately severe anemia.  On listening to her lungs, there was diminished air movement throughout, and faint wheezes when she breathed out, and her chest seemed larger than it should be for her overall size. 

I explained to her and her family that she needs to go to the medical post at Indiana and be tested for tuberculosis.  However, if this test is negative, I believe she probably has COPD, chronic obstructive pulmonary disease.  In developed countries, this chronic ailment occurs mostly in people who have been long-term tobacco smokers.  In places like this, it afflicts mostly women, who have spent hours each and every day of their adult lives laboring over a smoky fire in a partially enclosed kitchen.  She has probably never smoked a cigarette in her life, but she has certainly been exposed to a lot of smoke.  We gave her a nebulized treatment, and that seemed to help slightly, so we sent her home with medicines that will hopefully ease her breathing a bit (though I explained that if she does have COPD, there is no cure). 

Her husband's exam was fairly unremarkable except for the same pallor she had, and a bladder that was distended almost up to his belly button.  He also had a very low hematocrit, about the same as his wife's.  In a developed country, one would search for colon cancer, but here, their anemia most likely was due to small, chronic loss of blood to intestinal worms.  We managed to get in a catheter and empty the man's bladder, but we emphasized that he needs to see a urologist in Iquitos, as he almost certainly has an enlarged prostate, and will have this same problem again.  We also gave them worm medicine for the parasites that have probably caused their anemia, and iron and B vitamins so they can hopefully rebuild their blood, and instructed them to either boil their drinking water or chlorinate it, and to have their daughter do the cooking, preferably on a gas stove, if they can afford one.  We told them to return in a month so we can re-check their blood counts, and review the results of the TB test which she will hopefully have had by then.  One never knows whether patients will follow up on these things, but they seemed grateful that we paid attention to them and explained what we thought was wrong with them. 

We'll see.  

February

One day we saw a fifteen year old with a classic case of chickenpox, and a three year old was brought in with widespread pustules on his skin.  We gave the usual antibiotics, mom brought him back a few days later, unimproved, we changed the antibiotics, and he still didn’t improve.  This made me wonder if he might have MRSA, bacteria resistant to penicillins, so we switched again, and by gum, that did the trick.  That is good for this little boy, but rather ominous for the general population – we did not used to have resistance to antibiotics in this area; maybe now we do. 

One Saturday evening, a 20 year old woman came in after being bitten by a snake.  She actually lives in Iquitos, but has family in Yanamono, just upriver from the clinic.  She was three months pregnant, and that afternoon had lost the fetus (though not the placenta), so she came to Yanamono to be with her mother.  However, just as she stepped off the boat, she was bitten by a snake. 

I actually have some doubts as to whether the bite was poisonous, or perhaps she had a “dry bite,” i.e., a bite with no venom injected.  She did have prolongation of her blood clotting time, but not by much, and not much else – no significant swelling, hardly any pain, no other symptoms.  Still, to be on the safe side, she was given a vial of snake anti-venin.  Later in the evening, she went to the bathroom, and delivered the placenta.  By the morning, she was pretty much back to normal, and we let her return home. 

The next day, we had a two year old girl who had stepped on a nail and driven it deeply into the bottom of her foot.  There was an impressive volume of screaming as the wound was cleaned, but once it was all over, she was a little trooper, and smiled bravely, and even gave me a tiny peck on the cheek and accepted a little kiss from me in return.  Yet another unbearably cute little girl. 

Then, while I was in Iquitos, a woman brought in her four year old daughter who had gorged herself on shimbillo.  This is a fruit which grows in long wrinkled pods.  There are several varieties, with the longest reaching a meter or so in length.  Inside the pods are a series of shiny black seeds, about the size of marbles.  Each seed has an outer coating of a mildly sweet, moist white fuzz.  The usual method of consumption is to suck off the fuzz and spit out the black seed.  This child, however, had just gobbled them whole.  And she had gobbled a lot of them.  A day or so later, she had the urge to defecate, but couldn’t.  The clinic staff initially diagnosed constipation, and gave her lactulose, a laxative.  She returned the following day with belly pain, and still no bowel movement, and they counselled a little more time.  The day after that, she came again, and this time, on exam of her little butt, they could see a seed stuck in her rectum.  They took a forceps and removed it.  Then another one, then another, more than forty in all – after which, she had a nice poop and was cured.  

But not all our adventures take place in the clinic.  I happened to be in Iquitos running errands on Valentine's Day, and everyone in the world was out celebrating.  The few flower/gift shops in the city  were filled with men collecting obscenely overpriced roses and tulips, heart-shaped chocolates, and stuffed teddy bears holding embroidered hearts in their precious little paws.  At lunch, I went to three different restaurants before finding one without a waiting line (the one I wound up at serves mostly tourists, who don’t take Valentine’s Day as seriously as the Peruvians, so it was not so crowded).  And at night, the Plaza de Armas was packed with families strolling in the warm tropical night, young girls draped over the shoulders of their swains, vendors lugging huge racks of heart-shaped balloons, popcorn sellers hawking their wares, and again, packed restaurants.  Not only just young lovers but everyone got into the act, older couples, families, friends.  At the pizzeria, a couple my age was happily posing for a photo, arms cozily around one another. 

This is one of the things I like about Peru. 

While in Iquitos, I was able to talk with a man at the Ministry of Agriculture, in the Department of Agrarian Affairs, who keeps track of the river level.  He had a notebook filled with columns and columns of handwritten notations of the river level every day, for years on end.  He showed me how this year’s water level is well below what it was at the same date last year, which confirmed my own informal observation.  I asked whether he would be able to make any predictions, in a general sense, regarding the expectations for this year’s maximum flood level.  To my great relief, he replied that they are expecting that it will be lower than last year’s flood, which was itself a moderate one. 

After multiple years of unusually high and/or prolonged river levels, a nice, normal flood, maybe even one that doesn’t bring the Yanamono Stream out of its banks, would be so nice.  Of course, this does make me wonder what is happening with the glaciers in the Andes (I have heard they are disappearing, which could explain at least in part the lower river levels). 

March

After a relatively quiet January and February in the clinic, March picked up quite a bit.  For one thing, even though it is very early in the season (we tend to see malaria not when the river is rising, but as the flood recedes in June, leaving muddy, sloppy puddles behind it), there was a surge of patients with malaria, from several villages on the Napo River, and down the Rio Manati (on the far side of the Amazon from us).

April

Good news on the flood front: it looks like this year’s inundation is in fact going to be downright boring.  Typically, the Yanamono Stream overflows its banks somewhere around mid- or late March, and remains flooded till April or May.  In 2012, we set a new all-time record high water level, and in 2015, the stream escaped its confines the very first week of February (which has never happened before in all the time I have been in Peru), and did not return to its channel until the very end of June (also a record).  We have therefore been leery of our annual floods in recent years. 

This year, however, by mid-April, the stream has still not overflowed.  The man at the Ministry of Agriculture who showed me his notebooks, filled with meticulously recorded river levels for many years, who assured me that they are not expecting very high flood waters this year, was disappointed, because the farmers who plant beans and melons and rice on the river banks when the waters recede will have poorer crops than usual this year, since they will not have the silt load usually deposited by the floods. 

But he lives in the city, far from where the flooding occurs.  I am sure the farmers will still get a decent crop, and when one’s house stands on stilts, in order to permit the Amazon to flow beneath it when necessary, and especially after a series of years when one was living above water for weeks or months at a stretch, news of an impending non-flood is welcome.  

July

Ever since I got back to the clinic in early June (after a chilly but nonetheless very pleasant April and May in Wisconsin with Jerry), we have just been racing.  I am going to skip the April and May activity altogether, except to note that the clinic staff made three “campaigns” in my absence.  They traveled one day to a village which had a lot of cases of malaria, intending to do malaria tests on everyone, but since someone who will remain unnamed forgot to bring the necessary microscope slides, they instead tended to over 100 patients, including 57 whom they vaccinated, mostly against yellow fever.  A few weeks later, 63 students from the local school came to the clinic for sports physicals and well child care.  Then, the next day, the clinic staff again attacked another small downriver village, where they immunized 27 people mostly against chicken pox (a vaccine which we have never had before), provided well child care including worm medicine for 33 kids, and Juvencio pulled eight rotten teeth. 

One day, a 12 year old boy who had been bashed in the thigh while playing soccer a week earlier came with a nasty, swollen, exquisitely painful hematoma (collection of blood) in his thigh, from which we drained quite a bit of old blood and clots.  He wasn’t too pleased about the procedure, but did feel a lot better after all the bad stuff was out, and was much improved when he came back for follow-up a few days later.  There was also a 17 year old nursing mother who had a terrible abscess in her breast.  She too felt a lot better after we opened and drained it. 

Then there was a 21 year old woman who came in with right lower quadrant pain.  The possibilities for this are numerous.  She could have appendicitis, kidney stone (common here), ovarian cyst, ectopic pregnancy, urinary tract infection, constipation, and/or who knows what else that I did not think of.  She had a little blood in her urine but no nitrite, so maybe a kidney stone and probably not an infection.  Maybe.  Pregnancy test was negative, so probably not ectopic pregnancy.  But we had no way to differentiate between an early appendicitis and kidney stone, vs. Other.  We gave her antibiotics appropriate for appendicitis and infected urine, and told her to try to get an ultrasound. 

She came back a few days later with an ultrasound which showed hydronephrosis, fluid accumulating around the right kidney, which suggests blockage, probably with a kidney stone (at my age, one would wonder about a cancerous tumor, but at 21, this is less likely).  We gave her medicine which will hopefully make it easier for the presumed stone to pass.  Meanwhile, her 41 year old mother was there with her own younger daughter, now 15 months of age.  Besides this girl, and the 21 year old, she has six other children living, plus two more who did not make it past infancy.  Mom, are you using birth control? I asked, and she said yes, but had not gotten a shot since February (the Depo Provera lasts for three months, so she should have gotten her injection in May).  Why not? Well, they live in a small village downriver, and the local medical post doesn’t always have supplies, and ….  We confirmed that her pregnancy test was negative, and gave her Depo Provera.  

I happened to be in Iquitos running clinic errands when Peru played its first game in the World Cup in Russia.  Futbol (soccer) is a major topic of interest in Peru, and it seems their teams are not at the very top level of play, so it had been 36 years since Peru had qualified for the World Cup.  To say excitement was running high would be an understatement.  The team’s colors are red and white, and their uniform is a white shirt with a red diagonal band running from left shoulder to right waist.  On the day of the big game, probably 40% of the inhabitants of Iquitos were garbed in this t-shirt. 

I was at the Regional Health offices on the morning of the big game, talking with the woman in charge of the immunizations program.  Our conversation, however, was cut short as the game was about to begin.  Rows of chairs had been set up in front of a large tv in the open central area of the room, and someone had brought a big bag of popcorn.  I slipped away, wondering whether I would have trouble finding a motokar.  As it happened, although there were few of them on the road (though many clustered around every store, shop, and coffeehouse), there were also few people competing for transport.  Traffic was unusually light throughout the city.  Every place we passed that boasted a television screen was packed with eager onlookers.  When I passed by the Telefonica office, there were no lines, which is virtually unheard-of, so I marched right in and paid the monthly phone fee.  And when I went to the bank, my usual attendant was nowhere to be seen.  Someone offered, however, that she was “in the back,” and shortly she came out, wearing the Peru white and red uniform shirt.  

August

In July, we saw over 300 patients.  For one thing, the government apparently found a windfall of influenza vaccine, and launched a campaign to vaccinate everyone they could reach.  We immunized 150 adults and a bunch of children, and most of those patients had come for other medical services as well. 

There were as always several interesting patients.  My pride and joy is the young man who smashed his fingers while cutting wood with a chain saw.  The motorized saw was not what hurt him, it was the wood – a heavy chunk of it fell onto the middle two fingers of his right hand (of course, he is right-handed).  He arrived at the clinic shortly after the accident with his fingers wrapped in a blood-soaked rag.  When I unwound it, there was a gory mess (in medical terminology).  Both fingernails were gone (they were later found in the glove he had been wearing, and he expressed regret that they had not been saved as souvenirs).  About half of each nail bed was missing.  The very tips of the fingers were crushed, and all the skin had been taken off the pads of both fingers, down to the fold where the finger joint flexes.  The bones were not sticking out, but the tips of both fingers were gooey blobs. 

There are two bones in the thumb and great toe, and three bones in each of the other fingers and toes.  The proper thing to do for this young man would have been to amputate the third bone on each finger, and then use some of the remaining skin to fold over the wound and suture down.  But there was no skin left on either of the distal finger joints.  I would have had to take off at least half of the bone on each middle finger joint, and I’m not sure you can cut those bones (they’re not very large), so might have had to take the whole thing, which would leave him with only one bone in each of his two middle fingers.  As long as you have a thumb and a single finger, you can grasp a pen, a spoon, a button, etc – this is the function of a hand.  If we amputated half of each of the two middle digits, he would still have two full fingers and a thumb.  All the same ….

I told him look, if you can take the pain while it heals, we might, maybe, possibly, be able to let the smashed fingers grow back from within.  This is called “healing by secondary intention,” and works for some wounds.  If the fingers got infected, or if they didn’t heal well, we would have to resort to amputation.  It would take a lot of luck, as well as his patience – if the fingers were neatly amputated, they would heal in a week or two, whereas waiting for the tissues to grow back would take longer, and he would hardly be able to work during that time.  But if he wanted to give it a try … he did. 

We cleaned the injuries as well as possible, and left as much of the tiny remaining shreds of skin as we could, slathered the fingers with a commercially prepared aloe gel (aloe is good for wound healing, and we didn’t have much of anything else in the clinic that would keep the damaged fingertips moist without keeping them soaking wet), gave him antibiotics and a few tablets of tramadol and a lot of naproxen for the pain, and told him to come back in two days. 

He did, and returned every two days for the first week or so.  Miraculously, infection did not set in, and he was quite stoic.  By the end of the second week, the tips of both fingers were almost completely closed over.  These fingers are not very pretty.  But they are a great deal nicer than they were when he first came to us, and he will have the use of most of his hand, for the rest of his life. 

I like it.  

There was a patient who came to the clinic one Saturday afternoon, with vaginal bleeding and a mild anemia.  I had seen her a few months back with the same problem, found a large cervical polyp, and when I was unable to remove it myself, sent her to a wonderful gynecologist in Iquitos who was able to remove it in his office (and did not charge her anything for the service).  It was a leiomyoma, commonly known as a “fibroid,” and is a common and benign tumor of the uterine muscle.  The thing is, although these growths are not cancerous, they often cause women to have excessive vaginal bleeding.  And there may be more than one.  I told her to get an ultrasound, to see if she had any additional tumors, and she did not get around to it.  

She returned in early August, bleeding again, and again mildly anemic.  I did a pelvic exam, and her uterus seemed rather large to me, so we did a pregnancy test which thank goodness was negative.  I think she probably had more myomas.  She had plenty of living children, and no use whatsoever for her uterus. 

But she was in luck, maybe.  Centura Health is a health care organization out of Colorado, and their members have been coming to Peru for years, multiple times yearly.  Their usual routine is to bring two groups, one to perform surgeries at the Clinica Ana Stahl, across the street from Explorama’s offices in Iquitos, and another group to visit villages along the river and hand out medical supplies and occasionally discover a patient who badly needs their help.  They always come in on Saturday, then on Sunday morning, the surgical group evaluates patients and selects those on whom they will operate.  From Monday through Thursday, they perform surgeries, then Friday afternoon they relax, and spend a couple of days at Explorama.  They have been very helpful with several of our patients. 

As it happened, a group whose mission was gynecologic surgeries was arriving in Iquitos that day, and would be operating on women in the coming week.  If we could get her to them ….

Of course, that was easier said than done.  First of all, we are fifty miles from Iquitos, and there are no roads.  Then, she and her family live in a village well downriver.  She had not come prepared to go to the city and stay there for several days, yet returning home, then going upriver to Iquitos, would take way too much time -- it was Saturday afternoon, and she would have to be at the Clinica Stahl early Sunday morning.  And it was no easy matter to communicate with Centura, to let them know this patient would be arriving.  I told her that I could guarantee nothing, but if she could manage to get herself to the city, and show up at the Clinica Stahl the next morning, the Centura doctors might be able to help her.   I wrote her a letter of introduction, and told her to insist on seeing Sadith, the very helpful and enthusiastic young woman who is the coordinator for Centura’s visits.  She and her daughter walked out to the river's edge and caught a boat to Iquitos.  They must have arrived around midnight, then showed up in time Sunday morning, and Centura not only accepted her, she became their very first patient Monday morning.   While the woman and her daughter were heading to the city, I walked out to the edge of the river myself, where there is usually cell phone reception, and succeeded in reaching Sadith by phone to let her know about the patient.  I was in Iquitos running clinic errands a couple of days later, and stopped by the clinic.  The woman was lying in bed there, grinning ear to ear, pleased to finally be relieved of the organ for which she had no more use and which had been causing her such problems. 

Hurrah for Centura!

Guillermo

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