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Letters (Continued)

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I explained to her that she probably has hydatid cyst disease, which is a condition in which larvae of a dog tapeworm get into one’s body (don’t even ask), and multiply. They can cause very large cysts, and are fond of going to the lungs, and to the brain. I said look, you were told to follow up with the infectious disease people at the hospital, and you need to do that. Please go as you were instructed to do, and then come back here and tell me what they had to say. If they agree with the diagnosis, we can treat you with albendazole (though surgery would be preferable), and if they don’t agree, we will probably give you albendazole anyway. But you should check with them first, and if they want to operate and remove this thing, let them do it.

Dr. Linnea J. Smith Younger

The same day, one of our neighbors who has diabetes came in because she was out of her head. She had been to the clinic a few days before with diarrhea, and we had started her on antibiotics. Unfortunately, the antibiotic chosen was a sulfa-based one, and she was also taking a sulfa-based medicine for her diabetes. The result was that her blood sugar dropped to 42, which explained her ravings. We gave her sweets and brought her level back up to normal, told her to stop her diabetes medicines for a few days, and switched her to a different antibiotic.

And apologized – this is what is called an iatrogenic complication, which means the doctors did it to you. We made a note to ourselves, and will not likely forget it: do not prescribe sulfa to a patient taking a sulfonylurea. I have done this a number of times over the years and never run into this complication, but it is a known one, and we will avoid it in future. Happily, she recovered quickly.

Mother and Child

June, 2017

I once again returned to Peru after a cool and rainy but nonetheless delightful April and May in Wisconsin. It did not snow even once, and even if it had, any time that I am with Jerry is good time.

When I left Peru in late March, the water had just come over the path between my house and the dining room. My feet were not dry, but I was able to walk, in water which was finally a little above my ankles. Had I stayed another day, I would have had to resort to my dugout canoe to reach the dining room for coffee and meals. Still, this was an improvement on many of the last few years. In 2015, I needed the canoe starting in early February. This year's water level, for me at least, was tolerable.

And it remained so, more or less, though when I spoke with Edemita in late April she indicated that they were all tired of being stranded in the midst of all that water. Still, the river level beneath the clinic never reached more than a few inches in depth, and the water was about a foot deep beneath my house; levels which were far preferable to those of 2011, 2012, 2013, 2014, and 2015. By the time I arrived in the first days of June, the river was conveniently back within its banks, and although there was quite a bit of sloppy mud still around, most of the paths were walkable.

I'll take it.

June is the time of San Juan. San Juan, the supposed birthday of St. John the Baptist, is a minor or non-existent holiday everywhere except here (even in the rest of Peru, no one pays any attention to this day). In our department (state) of Loreto, however, San Juan is the occasion of major festivities. Dancing (and drinking) go on for several days, and everyone eats juanis. These are balls of rice seasoned with turmeric, with a piece of chicken, a piece of hard-boiled egg, and a black olive or two buried inside, all wrapped in a bijau leaf and boiled.

The week of San Juan, chickens perish by the tens of thousands. Juvencio claims it is the only time when a rooster becomes a hen – once killed and cooked, who is to know the difference? Actually, the best chickens are the ones raised locally around people’s houses, the gallinas regionales. There are chicken farms outside Iquitos where chickens are raised en masse, and they are ok, but the gallina regional is prized for its superior flavor. These animals tend to be tougher than tire rubber, but they do taste really and truly like chicken. The fist-sized rice balls are delicious, and readily portable, edible either with fork or fingers. As fast food goes, they are not only tasty but also environmentally friendly … once finished, you simply drop the empty bijau leaf onto the forest floor.

San Juan is also the time of periodic cold spells. These used to puzzle me – I had heard they were due to Antarctic cold winds coming up, and we are only a few degrees south of the equator. How do these frigid winds reach so far? It was explained to me that South America is a very thin continent in its southern half, and has cold oceans on both sides, and these factors account for the phenomenon.

The frios de San Juan, as they are called, seem usually to come in at night, with heavy rains and often with high winds roaring through the trees, sounding like a freight train gone mad. By morning, the temperature has dropped anywhere from 5 – 10 degrees centigrade (10 – 20 degrees Fahrenheit), and for the next few days, the skies remain clouded (though the rain usually stops), and the cold persists. When it is a strong frio, monkeys may die of exposure, and the local folks shiver. Those who have blankets pile them on the beds at night, along with towels, old clothes, any shawls one might happen to have around, and whatever else can be added for an extra layer of warmth. After two or three or four days, the sun begins to peek through again, the temperature moderates, and soon we are once again sweating.

Mother and Baby

August, 2017

Our last patient one afternoon was the daughter of one of our neighbors, now 14. As she and her mother approached, the girl could be heard crying loudly as she walked. What is the problem? -- belly pain. She had arrived ambulatory, and did not appear ill, despite her tears, so I waited while Elmer measured her temperature and blood pressure (both normal), then settled down and took her history. Did she have fever? -- no. Vomiting or diarrhea? -- no. How long had she had pain? -- oh, just recently. When was her last period? -- began last Friday and ended on Monday. Anything else going on? -- just a mild cold. What had she eaten today? -- oh, some salsa de cocona. A lot? -- well, yeah. And with what had she eaten this cocona? -- pijuayo, by any chance? Yes, pijuayo. (Pijuayo is the plum-sized fruit of one of the palms. You cut it in half, remove the marble-sized seed, and fill the cavity with a sauce made of cocona fruit mixed with cilantro and a little hot pepper, and they are delicious, if filling.) Ah, how many, then? --- five.

So, you ate ten pijuayo halves each filled with salsa de cocona, and now you have belly pain, and there are no alarm signals like fever, or tenderness where your appendix lives. Uh, yeah. Well, that seems pretty clear.

I reassured her and her mother, told her to walk, assured her that the pains would pass, and that once she moved her bowels that would probably help, encouraged her to exercise restraint when eating, and told them that in the US, the classic culprit for this sort of problem is green apples, which meant nothing to them. Her tears did not cease completely, but they did diminish significantly, and she actually smiled a few times as they left, armed with a few tablets of PeptoBismol and my admonitions.

Later, a neighbor’s mother came in, with complaints of urinary frequency. She appeared quite haggard, and I noticed her weight had dropped two kg. (about five pounds) since April. Her exam was unremarkable, but there was glucose in her urine, and her blood sugar turned out to be 518. We gave her a liter of IV fluids and a first dose of metformin, and told her to come back in the afternoon, by which time her glucose was down to 340 and she was feeling better. Here is another one who received the "take the medicine every day whether you feel like you need it or not" lecture; we'll see how she does with compliance.

There was also a racket one day as poor little Oscar Junior, one of our frequent clinic visitors, now 4 years of age, came up the steps crying and shrieking. Apparently, he had climbed up onto a table, but when he descended, he put his foot into a pot of hot peas stationed on a chair. He had blisters over his toes and the top of his foot, but not too much redness, and of course he was in pain and was terrified. Edgardo did a wonderful job of soothing him as he washed the foot gently, and applied a water-based dressing. He should do ok, if his toes don't get infected. Fortunately, though his mother is incapable of caring for him, he is currently under the care of an aunt who is very responsible.

And there was a 17 year old who came for her prenatal control. She already has a toddler at home, has no identification document, no vaccine card, and no prospects. I tried hard to convince her to go to Indiana, to the medical post there, and get into their maternal program, which will arrange for an ultrasound, as I believe her uterus is quite a bit larger than it should be for the 16 weeks gestation that she is supposedly at.

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