Amazon Medical Project: Fall Update

December 05, 2011
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The The Amazon Medical Project was founded in 1990 by Dr. Linnea J. Smith, M.D., who took her first Amazon rainforest tour with IE. The clinic 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 following is Linnea's November newsletter to friends and family.

Dear Clinica Yanamono Family, Friends, and Well-wishers –

When I first came to Peru to work in mid-1990, I brought with me a straw bag holding a microscope, a few pills, and a book or two, along with my doctor’s “black bag” containing very basic medical instruments – my stethoscope, a blood pressure cuff, and an oto-ophthalmoscope (the glorified flashlight used to peer into eyes, ears, noses, throats, and whatever other orifices might catch our medical attention). I set these few tools up in a room smaller than most people’s bedrooms, using a small desk with a thin plywood top as my office space, a single bed with a cloth-covered mattress as my exam table, and a kerosene lamp as my illumination. Pam helped me to find medicines in Iquitos, but in those days there was little to find.

Nonetheless, patients came in slowly but steadily increasing numbers; and then in 1993, those marvelous Rotarians came and built a lovely clinic out on the edge of the river. I trained first Juvencio, then his sister Esperanza, and when she left, I trained Edemita, and we all worked together.

I remember sitting on the back stairs a few years after that clinic was built, marveling at our clean, painted, thirty by sixty foot building, with two exam rooms, a pharmacy, an office, an overnight room for patients, a bathroom, a small kitchen and lab, and an overnight room for me, when I needed to be there for emergencies. There were solar panels to provide electricity, and a well for water. The closets were filled with donated instruments, there were shelves in the pharmacy and they were stocked, there were genuine exam tables, with stirrups for pelvic exams, and patients were arriving daily. How on earth did this all come out of that small armload with which I started???? It impressed me no end.

Then when the river ate the land on which the clinic stood, and our wonderful Rotarian friends built a new, even larger clinic on the Yanamono Stream, I saw how much we had outgrown the first clinic. We were seeing more patients, we had staff living on-site, we had more equipment – in 1993 when the first clinic was constructed, we did not have a vaccine refrigerator, nor an electrocardiogram program, nor a computer or printer – and we had been working out of a space that had become cramped.

When I first began to see patients in that thatch-roofed room at Explorama back in 1990, I saw a total of 115 patients in four months. By the time the Rotarians built the first “real” clinic, we were averaging around 100 per month. Last year, an average month brought almost 250 patients – a total, over all the years, of over 45,000 patient visits.

And the changes won’t cease and desist; we continue to grow. When we hired Carmen, almost four years ago, she, Juvencio and Edemita were able to provide nursing services for all our patients, keep the clinic clean and the linens washed, and stock all the materials in the exam rooms and pharmacy. With one full-time doctor at the clinic (two, for the months when I am in Peru), plus three full-time clinic assistants, one would think we would have good staff coverage. But the Peruvian doctor gets ten days a month off, plus another day or two for travel to and from Iquitos, where she lives when not at the clinic. The other staff members each have seven days off monthly. And everyone gets a full month of vacation each year. We attempt to coordinate our schedules so that there are usually three people at the clinic, or at least two, but it is impossible to foresee all eventualities. In May, for instance, Carmen was gone for half the month on her vacation, scheduled well in advance. Then Yasmina’s mother fell ill in a distant city and Yasmina went to care for her, using not only all ten of her May free days but also most of her days from June, which caused her to be absent from the clinic from the morning of May 2 till the afternoon of May 21, nearly three weeks in all. And Edemita spent two or three weeks in Iquitos struggling with her asthma.

I reconstructed the calendar for that month, and for the entire first half of May, there was only one person on duty on any given day. Yasmina was there on the 1st, while Juvencio was in Iquitos with an abscess in his knee, Carmen was on vacation, and Edemita was running errands in the city. From the 2nd through part of the 6th, Edemita was alone. From mid-day on the 9th, through Sunday 15, Juvencio was the only person working. For the 7th and 8th (a weekend, when Edemita had gone to Iquitos because she was unable to breathe), and again on the the 16th, there was no one at all to care for patients. From the 17th on, there were two people on duty each day for most of the time, until the 27th, when Carmen, Edemita and Yasmina were all again back at work, while Juvencio was out for a week and a half with Dr. Jeannette Grauer, who came for her annual dental campaign. It’s a wonder they managed to take care of 192 patients in the month.

Of course, not all months present staffing problems like that, but especially when I am in the U.S. and Edemita needs to be in Iquitos to make clinic purchases and run other errands, it seems that we are too frequently stretched too thin. Furthermore, the very clinic itself, with a footprint somewhat larger than the original clinic, and considerably larger grounds, requires more in the way of maintenance and upkeep than can be accomplished by our current staff. There is now too much surface area in our walls for the nursing staff to keep the mildew washed off, and sometimes the linens pile up before getting washed; we have had to bring in local people occasionally to help with these and other chores.

When we have searched for nursing personnel in the past, it has been a challenge, to say the least. Most new grads are not very well-trained, which can be overcome if they are willing and able to learn. Unfortunately, not all seem to be capable of learning.

In August, when Doctora Yasmina took her annual vacation, we hired a temporary replacement doctor, and his girlfriend came to visit him one weekend. She had just completed her studies as a registered nurse, and needs to perform several months of student nursing in a rural area. We were all impressed with her when she was at the clinic for that day or two – Edemita reported that she filed and cleaned, quickly learned our charting system, fitted in easily with the other staff, and went looking for work to do if patient flow was slack. We have therefore taken her on for her student nursing; if she works out well, we will probably try to hire her.

We are expanding in other ways, too. Juvencio continues to expand his dental skills and is now doing some reconstructive dental work, in addition to the tooth extractions that we have been performing since 1993. Last year, Doctora Yasmina suggested that we offer dental mapping, wherein each child who comes for our well-child care program is examined by Juvencio, who then charts which teeth are healthy and which are in danger. This will hopefully enable us to save at least some of those teeth at risk.

We have also added diagnostic capability with an electrocardiogram program, and our wonderful new ultrasound machine.

Then, years ago, we started what we call the Special Patients Fund to help provide services not available in the clinic. This program has found increased use as we encounter patients who need laboratory studies that we do not offer. For instance, when Juan comes in repeatedly with abdominal pain that does not respond to any of the medications we give him, we can ask him to go to Iquitos for endoscopy, and when he brings us the report of the study, and the receipt for it, we reimburse him.

And of course, as you know from previous letters, we seem to be seeing an increasing number of patients who require emergency transport to Iquitos, which has always been a thorny issue since we do not have our own boat.

I debated for a long time on this topic. We have been taking care of patients for over 20 years without a boat, so why get one now? When it was really necessary, we have usually managed to find some way to get a critically ill patient to the government health center at Indiana, at least. If we have our own boat, will women in labor wait until they’re in trouble, then come to us with the expectation that we will just zoom them into the city and save them? Will people want to borrow the boat to go to very important soccer tournaments, or to get into the city because they have received word that a relative is ill? We only need to emergently transport someone maybe ten times a year, and a boat costs thousands of dollars, plus the ongoing costs of maintenance, and gas to get to Iquitos and back will be over $150 per trip. If we have a boat, will we be tempted to transport people who in the end turn out not to have really needed the service?

But, this year has seen quite a number of people who really did need more help than we could give. There was the man who turned out to have a perforated intestine due to dengue hemorrhagic fever. There have been several women with difficulties in labor, and a woman in labor in trouble makes all of us very nervous. There was the young child with respiratory problems. And there was Azucena, who died at 25 years of age a few hours after developing acute respiratory failure. There was a significant delay in her treatment due to the fact that, after we took her to the government medical center upriver at Indiana, it took many hours before they were able to get her on a boat to take her to Iquitos. I suspect she would have been doomed anyway, but I cannot help wondering, if she had gotten to the city earlier, would she still be alive?

And just a few weeks ago, there was the 50 year old man who came in with what looked like appendicitis. Juvencio accompanied him, in a boat borrowed from Explorama, to the Indiana health center. There, they were informed that the health center’s boat had sunk (no surprise to me, as I had ridden in it with a young child a few months earlier and knew it to be in very questionable condition), and anyway their motor was out of commission. Juvencio therefore accompanied the patient to Iquitos in one of the boats for hire who ply the 25 mile route between Indiana and the city, with the patient sitting upright on one of the hard benches as the boat bounced along for an hour or so. When they reached the hospital in Iquitos, he was found to have not only appendicitis but also a necrotic appendix (i.e., it was rotten, although luckily for him it had not yet burst). Had he remained at the clinic, he would have died a miserable death.

Although we have been able to beg or borrow or otherwise cobble together some form of makeshift transportation when we needed to, we have tried the patience of those who have boats potentially available to us, have felt more than once that we should have taken a patient all the way to the hospital in Iquitos rather than leaving them at the government center in Indiana, and, when we have gone ourselves in the Indiana boat to the city, have had harrowing rides.

Taking all this into consideration, when Carlos Acosta, a neighbor, friend, and active member of the Rotary Club in Iquitos, offered to donate a used boat to the clinic, we took him up on it. A number of individuals contributed to pay for the repairs to the boat’s shell, and to add the seats, roof, rain curtains, life jackets, wooden floor, and all the other sundry and assorted items needed to turn it into a usable vehicle; then the Duluth Rotary Club #25 came up with the rest of the funds to complete those necessary improvements. Explorama offered to donate the motor, but that would have meant significant complications when it came to registering the boat (one entity owning the boat and another owning the motor would have been a difficult arrangement to explain to the port authorities). But David and Sandy Longhofer and a group of their friends came to the rescue with a combined effort that brought in enough to buy a new 40 hp Yamaha outboard, so we are just about ready to go.

That is, once the boat gets registered. The first time I went to obtain a driver’s license in Iquitos, it took three days of errands among various functionaries and departments (I was not sure I wanted to know why they needed to know my blood type in order to give me a license to drive a small motorcycle), and that was with the personal assistance of a highly placed man in the police force, complete with uniform and epaulettes on the shoulders, who shepherded me around to all the offices we needed to visit. Boats, I am told, are somewhat more complicated. But I have confidence that by the time I return to Peru after the holidays, we should have our own, clinic-owned transport. Hurrah!

We’ve come a long way, baby, and it is all thanks to you. May’s 192 patients were the lowest monthly tally we have had so far this year; whereas when we opened the original clinic in 1993, 192 patients would have constituted a very busy month. This is a little scary … there are now thousands of patients depending on us, not to mention seven full-time local employees and their families, whose livelihood is the clinic, and each year’s annual report shows that we have spent more than the year before. On the other hand, it does mean that the clinic remains interesting, and lively, and I thank all of you for making it possible to carry on. May you all have a joyous holiday season, and a hopeful New Year.