Amazon Medical Project: Summer Update

August 17, 2010
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The Amazon Medical Project supports the Yanamono Medical Clinic in the remote Amazon basin of northeastern Peru by providing primary care, involving locally trained people and encouraging preventative medicine. The clinic was founded in 1990 by Dr. Linnea J. Smith, M.D., who took her first Amazon rainforest tour with IE. The following is Linnea's newsletter to her friends and family.

When it rains, it really does pour, it seems.  And as everyone knows, we live in a rainforest.

After a lovely April and May in Wisconsin with Jerry, I arrived back at the clinic to find it busy. Within an hour of my hitting the ground, Wilbert took his leave, off to search for a residency position in Lima. He reports that he did well on the test, but did not succeed in gaining a residency. Nonetheless, he was gone for nearly three weeks. This of course means that I am back to being The Doctor, in addition to administrator, purchasing agent, accountant, personnel director, public relations manager and CEO.

And the busy streak that began as soon as we moved into the new clinic (over a year ago, now!) has not faded.

I spent the first few days trying to unpack and put things away, but kept being distracted by more patients arriving.  Finally, I got away to Iquitos to make purchases, buy medicines, run errands and collect supplies. In talking with Miguel Angel, the curator of the vaccines, I asked if the long-awaited vaccine against Swine Flu had arrived, and he affirmed that yes, it had. Great, I said – can you give me 50?  He acquiesced, we filled out the papers, and I collected the 50 vials along with the other vaccines.

I ran the remainder of the errands and returned to the clinic, hoping to unpack everything, put it away, and perhaps start recording the expenses in the account book; but it was not to be.  I had hoped to get back to the clinic early Friday afternoon, but did not arrive till 4:00. When I walked in, I found that little Elmer Melendez Murrieta, three years of age, had tangled with a cascavel an hour or so earlier. (Cascavel is a small member of the rattlesnake family, whose venom is thought to be much more potent than that of its larger relatives.) He must have really annoyed that snake, because he had reportedly been bitten not just once, but three times.  Juvencio, Edemita and Tiffany, our wonderful June volunteer, had taken a specimen of blood for clotting, and it didn’t clot at all. Furthermore, he was bleeding briskly from his gums.  Then, just in case I was not yet worried, they reported that when he got to the clinic, his foot was pretty much normal except for three small puncture marks; but by the time I arrived, only one hour later, the entire foot was swollen and blue. They were trying to get an IV line in, but without much success. Fortunately, I was able to slide one into his antecubital vein, where they had drawn the clotting specimen earlier, and we got antivenin into him; but unpacking and tallying of purchases and medicines got pushed off till later.

Then, at supper the lodge administrator told me that the only boat going upriver the next day would leave at 5 a.m.  Edemita needed to be on that boat, because there was a group of visiting surgeons who were going to take her gallbladder out on Monday.  Also, Carmen was in the city for her days off, so on Saturday, we were down to just Tiffany, Juvencio and me. And it was a busy day, again.

Sunday was happily a little more calm, with only a few patients, and only a brief worry, when Edemita called from Iquitos to say that she was at the Clinica Stahl, and her name was not on the list of those to be operated on. Fortunately, the leader of the group was expecting her, went looking for her, found her, and saw to it that she got on the list, for Monday surgery.

While Edemita was in Iquitos awaiting her surgery, Carmen, Tiffany and I were at the clinic, and on Monday, we had a total of 38 patients, maybe a clinic record for a non-vaccine day, although it did turn out to be a vaccine day of sorts.  Once I was in the clinic and looked more closely at the vials of swine flu vaccine, I realized that each vial contains ten doses. We thus have 500 doses, and they will expire at the end of July. Having acquired those 500 doses of the coveted H1N1 vaccine, it behooves us to apply them. For years, I have pleaded, cajoled and begged people to get their vaccines, but now, for the first time ever, folks are showing up actually requesting to be vaccinated against Swine Flu. Thus, virtually everyone who comes into the clinic this month who is over four years of age, not already immunized, and not really sick gets the vaccine. We vaccinated 26 people against Swine Flu on Monday alone.  Some had come with other problems, though, and if we discount the 13 persons whose only service was the H1N1, we still had 25 patient visits, which is a very busy day.

The first patient was a man in his 40's who had come in the day before with fever, body aches and general malaise.  His malaria smear was negative, and I thought he probably just had a viral syndrome. Nothing to do but take ibuprofen to bring down the fever and calm the aches, and wait for it to go away. If he was not feeling better in two or three days, I said, he could come back, but he was having none of it. At 11:00 that night he decided he could not stand it any longer, and returned to the clinic, moaning and groaning. I was relieved that Carmen had cut short her days in the city and returned to work on Sunday afternoon, so she took care of him overnight. Monday, she smoothly triaged, vaccinated, etc., etc., while Tiffany and I did the rest of the work.

Among the patients were several little ones with colds — there has been a wave of respiratory ailments in the last month or two. Monday, the kids were all doing pretty well, but we have seen some very sick babies, including one who died from pneumonia (well, pneumonia and severe malnutrition; at over one year of age, he did not even weigh ten pounds).  Now that many villages along the river have water treatment plants to provide clean drinking water, we are seeing fewer patients with diarrhea, but we did have a couple of those on Monday, too.  Then there was an older man with a very sore shoulder, I think due to a rotator cuff injury; and a 13 year old who needed sutures removed from a laceration he had suffered a week earlier; and an eight month old for dressing changes — he had pulled a big pot of soup over on himself a few days earlier, and burned much of the front of his body, as well as both hands — and our young snakebite victim, who was not yet able to bear weight on his injured foot but who did have less swelling and no more bleeding from the gums.  There were several women for family planning, one for a Pap smear, a couple with urinary infections, and finally, a 26 year old man who had a bad case of pneumonia.

Subsequent days have been similar. Once in a while we get a lull, but we have seen around 300 patients this month, and still have a few days to go. Dr. Wilbert came back to work last Monday, then left again on Thursday afternoon to take a woman in labor into the city. She is not quite 18 years old, and is small even for around here. Her mom and sisters and she are all well under five feet tall, and her pelvis was just too tiny for a baby to squeeze through. Wilbert got her part of the way in an Explorama boat, then they caught a speedboat that was passing, and she had a Cesarean section in Iquitos. He reported later that she and the baby both did fine.

He was still gone, though, on Friday, June 25, and we had 20 patients that day, with only me and Juvencio to take care of them all. These included a young woman who had a terrible breast abscess. I drained it, and you would not have wanted to see what came out. (The nice thing is, with the drainage and the antibiotics, her fever should go down and her pain should improve, and the whole nasty thing, with a little luck, should heal up quickly.)  There was also a 16 year old from a village out on the Napo River who according to his parents had broken his leg the day before. They knew it was broken because they had seen the bone come poking through the skin.  (Why had they not come the day before? — No boat available.) I clambered down the muddy bank and took a look at him in their boat, but shook my head. I could see the wound where the bone had pierced the skin, and knew he needed more care than we could provide, starting with an x-ray to see exactly where the bone fragments were located. His parents were disappointed to hear that we do not have x-ray (hey, I said, we are just a country clinic). I settled for giving him a tetanus vaccine, a dose of injected antibiotics, and a note for the doctor at the government health center at Indiana; and off they went in their pequi-pequi boat.

So far, it has been quite the month.

And, the river is falling daily. Despite the torrential rains in Cusco early in the year, this year’s annual flood was not much. The stream did not even get out of its banks at the clinic or at my house. Now, the water is dropping rapidly, and soon we will be walking across. For the moment, however, each day means negotiating a longer stretch of mud in order to reach my dugout, which I use to cross the stream to get to the clinic. The higher ground has dried out and is pretty firm, except when it rains (did I mention it has been raining a lot, lately?), and then the surface takes on the slick, slippery texture of wet potter’s clay. The farther down I go toward the stream, the softer is the mud … putty, then pudding, and finally slop. Golbert, who lives on the far side of the crossing, has been wonderful about putting out ever longer handrails and pieces of old lumber embedded in the muck to provide firmer footing. It is still quite a challenge, though. The other day, I successfully entered the canoe and pushed off from the bank, only to leave my paddle stuck in the mud as I floated gracefully, backwardly, across the stream. I used my hands to propel myself back and retrieve the paddle, but it was a bit of an operation, and I am sure that Golbert’s family has been deriving daily amusement from observing the gringa’s efforts to get into and out of her canoe.

Now comes a sad note … we bid goodbye to Peter Jenson, aka Don Pedro, on June 20. Peter is the man who came to Peru in the early 1960’s, stayed and founded Explorama. Hundreds of Peruvian workers, past and present, owe their livelihoods to the company that Peter built, and the Clinica Yanamono could never have existed without his generosity in feeding and housing me for many years.

Last fall, Peter was found to have esophageal cancer. His sister lives near the Mayo Clinic in Minnesota, and Peter went there for treatment. Studies showed that the tumor was limited to his esophagus, and surgery was undertaken in January. Unfortunately, just before his return to Peru in May, the tumor was found to have spread, with multiple metastatic lesions.

Peter’s greatest wish was to return to his home on the Amazon, and he was able to do so, and spent several weeks in his beloved rainforest, in his own home. On June 19, he showed a burst of energy and walked as far as the dining room.  That night, he slept through the night. In the morning, it was very difficult to awaken him, and by mid-morning, his breathing slowed, then stopped. We are all grateful that he went without pain, in the comfort of his home, with Pam and his faithful nurse at his side.

In these parts, the custom when someone dies is to hold what is called a velorio, which is a sort of wake. Friends and relatives gather to bid goodbye to the deceased for the entire night, and burial takes place the following day. In Peter’s case, the Amazon Queen, Explorama’s three-decker large boat, brought him from his home at Ceiba Tops 25 miles downriver to the Yanamono Lodge, so that employees and friends there could say their goodbyes, then back up to Iquitos where residents of the city who had known him had an opportunity to pay their respects. Hundreds turned out at each stop, including the first one near the Lodge, despite the fact that the Amazon Queen arrived at 10:00 at night. At noon on June 21, he was cremated, and one day soon, his ashes will be spread over the rainforest from the highest platform on the canopy walkway, which was his desire. I can think of no more fitting farewell for a man who made such an impact on so many people, over so many decades.

Rest in peace, Peter. After more than 40 years of adventurous living in the Amazon, you deserve it.