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Letters (Continued)

Continued from the previous page.

Dear Clinic Family, Friends, Supporters, and Interested Onlookers 

Oh, my, yet another year has passed, so it is time to give you all a summary of what we have been doing with the contributions you have so graciously and generously made to the Amazon Medical Project. 

We’ll jump right in with patient numbers – up a little from 2017, with a total of 2,907 people coming to the clinic.  Most of these (2,856) received some sort of service, while the remaining 51 simply purchased toothpaste or ibuprofen, etc.  As usual, children (that is, people up through the age of 14 – there are enough 15 year old parents that we count them as adults) accounted for about 40% of the total, with adults making up the rest.  About 5% of our patients were 70 years of age or older, which is an increase over previous years, in fact is double the tally of a few years ago.  Maybe we’re making a difference.  Also as usual, females outnumber males, roughly 60/40.  This is partly because women are the caregivers who bring their families in for treatment (and come themselves for family planning), and partly because the men tend to congregate outdoors in the covered shelter area, fearful of being subjected to a needle prick if they venture within the clinic walls.  I sometimes go after them and cajole them in for vaccines. 

Young Boy on Examination Table

We provided family planning for 341 women, and did Pap smears for 23.  We saw 49 cases of malaria, more than in the last few years, though fortunately, all survived.  There were a half dozen poisonous snakebites, and all of these victims survived, too.  There were other animal adventures, as well, starting with a couple of impressive catfish spines lodged in people’s extremities.  These spines are durable cartilaginous structures, barbed all along their length, so pulling them out is painful, but they make good souvenirs once removed.  There were a couple of dog bites, several scorpion stings (and in 2018, for the first time, we actually have anti-venin for scorpions), a wasp sting to someone’s eyelid (ouch), and a spider bite or two.  We have no spiders in this area that are likely to inflict fatal wounds, but there are several whose bites are reputed to be quite painful.  And there was one seven-year-old girl who had the misfortune to be stung by a sting ray, on the back of her ankle.  In addition, we treated several people who had run afoul of biting ants.  There are a large variety of ants in the rainforest, most of them bite or sting or both, and some are quite painful, especially the very large ones.  A bite from a single isula, an inch-long, highly unfriendly ant, is enough to make a grown man weep.  One of our neighbors was inflicted with three bites, although he was incredibly stoic about it. 

We saw a total of 71 emergencies in 2018.  Some of these would not have been emergencies, had they occurred during regular clinic hours, but sometimes people present with diarrhea or pneumonia or headache or belly pain in the night-time hours, or over the noon break, and of course trauma patients do not always suffer their injuries during regular clinic hours.  One of our off-hours patients was a four year old child who became constipated after she had gobbled handfuls of a local fruit which has a very large seed surrounded by a thin layer of sweet tissue.  Normally, you suck off the sweet outer layer and spit out the seed, but this child just ate them whole.  Lots of them.  Her mom brought her in a couple of times; the second time, Edgardo manually removed over forty of the large seeds from her rectum, and she was cured.  Then there was a ten-month-old girl brought in late one afternoon, with pneumonia and a febrile seizure.  Febrile seizures in a patient this age are not usually dangerous, but they are quite frightening to the parents.  Happily, this little girl did well with antibiotics, and we sent her home the next day. 

We evacuated a dozen patients to a higher level of care in 2018, with mixed results.  The first was a 44 year old woman with general decline for a month or so, and obviously yellow skin.  She had malaria, but was also a daily consumer of the local sugar cane rum, and appeared ill; in Iquitos she was diagnosed with pancreatitis, which may or may not have been the case.  We have not heard any more from her, and I suspect her prognosis was not good.  There was a five year old boy with belly pain and swelling, who worried us all, so we took him to the medical post at Indiana.  However, when I later went to the Regional Hospital in Iquitos, they had no record of him.  Eventually, we were able to contact the family, and according to his mom, he had been given an injection (of what medicine, for what ailment??) at the government clinic in Indiana, and by the time he got to the Regional Hospital was so much improved that the doctors there declined to bother with him.  Who knows? – but he did seem to be in fine health when she brought him in for follow-up.  There were several people whom we transported with suspected appendicitis, but nowadays this is often treated with antibiotics, and the only two who actually underwent surgery were one man from the local village who had been coming in repeatedly with the same symptoms, and a teacher from a village upriver who was forced to travel to Iquitos on her own dime, because as a teacher, her health care coverage was not the same program as that offered by the Indiana medical post.  There were a couple of children with belly pain, whose outcomes we do not know.  And there was a tragic case, a thirteen year old who came to the clinic one evening when I was in Iquitos and the Peruvian doctor was also away.  According to the nursing staff, she appeared quite ill, and could not swallow, which was worrisome for tetanus, especially as she had been bitten by a poisonous snake a few weeks earlier (she did not come to us for that), and tetanus sometimes follows a snakebite.  We do not know what transpired at the government health center, but for whatever reason, she was taken home by her parents, and died there a few days later.     

We delivered no babies in 2018 in the clinic, but did take several pregnant women to the posta at Indiana because they were bleeding, in labor at a very young age, or in labor prematurely.  I know everyone wants us to deliver all those adorable babies, and as soon as someone can guarantee that all deliveries will occur at 9:00 a.m., following one hour of labor, with no unpleasant surprises for either mom or infant, I’m on board.  Until then, though I agree an uneventful delivery is a satisfying event, we will continue to provide prenatal care (as we did for 26 women in 2018), but will strongly encourage women to go to a higher level medical center rather than trying to give birth at the clinic, just in case something unexpected and potentially life-threatening occurs. 

We saw 41 trauma cases, mostly relatively minor.  In most homes, cooking is still performed over an open fire, which means not only opportunities for burns but also for machete cuts, as people chop their firewood.  Other machete cuts occur when someone falls, such as the five year old boy who slipped while carrying his machete and stabbed himself in the arm (of course a five year old is carrying a machete, how else could he cut firewood so his mom can cook breakfast?).  One young adult in July sustained a partial amputation of two fingertips when an intended chunk of firewood fell on his hand; we avoided completing the amputation, dressed the wounds with aloe, and were pleased when he healed.  There are always soccer-related injuries, ranging from sprained ankles and twisted knees to banged heads.  One young man took a soccer ball to his privates, which although not fatal was distinctly uncomfortable for him, for a few days.  And a fourteen-year old who was out hunting, with his shotgun at the ready, slipped, fell, and shot himself in the thigh.  This happened to be at a moment when there was no physician in the clinic, so Edgardo was the one who put in 37 stitches in the deeper tissues, and another 17 in the young man’s skin.  He recovered, but had a painful time of it for a while.  There are also a few puncture wounds from nails, and we are careful to make sure these patients receive their tetanus vaccines.  

We vaccinated 543 people, against a variety of diseases.  The government again launched a campaign offering influenza vaccine in 2018, and we vaccinated many people, both young and adult, for this common and occasionally devastating illness.  Routine vaccines include polio (essentially eradicated, but no one wants to take any chances), DPT (diphtheria, pertussis, and tetanus, the last two of which illnesses are nowhere near eradicated), rotavirus, pneumococcus, yellow fever, hepatitis B, Hemophilus influenzae B, Measles/Mumps/Rubella, and Human Papilloma Virus, the agent implicated in cervical cancer.  Cervical cancer is a tremendous scourge here, and probably in other developing countries, and I am hopeful that the current generation of young women will not have to contend with it in the future.  The government also delivered one shipment of vaccine for varicela (chicken pox), but we have not been able to get any more of this vaccine since then. 

Pneumonia and diarrhea have always been killers of small children, in all developing countries, and both these problems seem to be improving.  The reduced numbers of cases of pneumonia (41 in 2018, half what we saw the year before) are probably attributable to the pneumococcal vaccine, and the reduction in diarrheal illnesses is certainly related to the proliferation of clean water projects, both for villages and for individual families.  Nonetheless, we still saw 172 patients with diarrhea, and many of them required intravenous fluids. 

Skin problems are always a popular ailment in this tropical climate, where fungal infections (ringworm, athlete’s foot, vaginal candidiasis, pityriasis, etc.) thrive, and where people’s immune systems are, I believe, suppressed compared to those who live in better nourished countries.  Scabies occurs regularly, as does herpes zoster (“shingles”), impetigo, infected skin lesions, warts, contact dermatitis, and hives (actually an immune problem, but one that is manifested on the skin). 

Juvencio performed dental extractions for 36 people, and even better, was able to save teeth for 21 others, either by filling cavities or by restoring broken or damaged teeth. 

And, there are always patients who fit into no particular category, but who make our lives interesting and keep us on our professional toes.  Early in the year there was an enterprising three year old who not only stuffed a piece of sponge up his nose, but also plugged his ear with toilet paper.  Extraction of the foreign objects was a noisy affair.  We saw a man who had reached the advanced age of 94, brought in by his sons for a bit of a cough; he was one of those who regularly smoked the local tobacco in hand-rolled cigarettes for years, and probably had COPD.  He also had a bulky lesion in his anus that might have been hemorrhoids or might have been cancer.  Since he is already well past the average life expectancy in this region, and at his age would be unlikely to tolerate either surgery or chemotherapy, we settled for giving him medicines to help his breathing, and let the anal lesion go.  One of our neighbors came in with drainage from her ear, and pain not only in the ear but also when she tried to swallow.  She had been cleaning her ears out with Q-tips, which is a popular practice but not a good one.  She had swelling in the ear canal, and nasty drainage, which means she had otitis externa, infection of the ear canal.  However, the swelling in her neck suggested she might have malignant otitis externa, which can involve bone, which is a potentially very bad illness.  She healed with antibiotics, though, which was a relief all around.  A 46 year old woman presented with vaginal bleeding for two years.  Fortunately, she did not have cervical cancer, just a large myoma (“fibroid”), which a kindly gynecologist in Iquitos removed for her at no charge.  (He has helped us with other patients, too.)  Another female patient was not so lucky.  She was 43 and had given birth at home, apparently uneventfully, but then the placenta refused to come out.  It was not clear who exactly had done what, but someone had wrapped a stick around the cord, which implies that force was applied in an attempt to pull the placenta out.  Probably, it was firmly stuck to the inside of her uterus, because the family members who brought her said that at some point there was a substantial gush of blood, and she died en route to the clinic.  Her newborn daughter was blue when she arrived, but the clinic staff revived her, although without a mother, her future is dubious.  If a wet nurse can be found, she will be raised by family members; if not, she is probably doomed.  Oh, and I removed a piece of shot from the foot of a man who had had a hunting accident in 2004.  This piece of lead had worked its way near the surface, so I gave it to him to add to the others I took out years ago. 

We also made a couple of outreach efforts, providing sports physicals to 54 adolescents in early May, followed the next day by a voyage to a couple of villages downriver where the staff vaccinated 27 people, mostly with varicela vaccine (against chicken pox), provided Well Child Care to 33, and pulled rotten teeth for eight others. 

And we had some follow-up on a young man who had worried us a couple of years ago.  He is now 17, lives in a village well downriver, and came in with malaria (and pretty noticeable anemia, which improved with iron and vitamins).  But in looking through his chart, we noted that we had seen him a year earlier, with a baseball-sized lump in his armpit.  An ultrasound at the time was very suspicious for a malignant lesion, but the only treatment he received was massage of the area by his mother, who used an old sandal for the purpose.  Amazingly, the mass disappeared.  I had him go for a follow-up ultrasound, funded by the clinic, and there are still two enlarged lymph nodes in the area, one measuring 13 mm., the other 19mm.  Otherwise, there is no trace of the mass.  This is a mystery, and I only hope that whatever it was does not return. 

And we took care of a 41 year old woman for about six months.  She was diagnosed in Iquitos with cirrhosis of the liver, probably as a result of Hepatitis B when she was a child.  Because of the cirrhosis, her abdomen kept filling up with fluid, and once or twice the fluid was probably infected.  We would drain off a gallon or two, she would breathe more easily, and then we would see her again in ten days or so, once the fluid had re-accumulated.  She died toward the end of the year, but I think her last months were at least somewhat more comfortable than they would have been otherwise. 

And of course, there were a couple thousand other patients whom we treated. 

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