THE PATIENTS

Little girl with snake bite being taken from Rumi Tumi to

Clinica Santa Clotilde

By Dr. Baldoceda:

You see everything here! My bread and butter: diabetes, hypertension, arthritis, chronic kidney disease...it's all here, but there are few of those patients. The most common things they see here are Malaria (both Vivax and Falciparum), infectious diseases...all kinds of GI parasites, TB, upper respiratory infections, and chronic malnutrition. Everyone that comes in to the center complaining of a fever gets tested for Malaria...it's basically a vital sign. There are some patients that have been treated for Malaria 19 or 20 times. We have diagnosed Dengue Fever, although this is much more commom in Iquitos than the Napo. Needless to say, I'm pretty much soaked in bug repellent.

It's been an interesting week in the hospital...
We had two infants with 2nd degree burns. One walked right into the flame that her his mom used to cook and the other was a hot water scald... it was awful. It was her whole face and part of her back. They both got antibiotics, IV fluids, and dressing changes and are both now home. The team asked me, how we managed serious burns...ha, um...I'm don't...thank god for ERs and burn centers.

Then there is little Vlademir who is a 7 year old boy who came in with osteomyelitis of his L elbow and R leg. There is no imaging technology here, so it's pretty much a clinical diagnosis. The day I arrived they had peformed an osteotomy under sedation w/Atropine and Ketamine. Ketamine is their anesthetic of choice here...it's the only anesthetic used. 2 days later, Padre Jack went back in to extend the incision a bit for better drainage and I saw the opening into the bone. I've never seen this procedure before, probably b/c we don't see a ton of osteomyelitis in the US that gets to this point, apparently pus oozed out of this kids bone. Anyway, he's doing great...fever free for the last 3 days and now he's with us for the next 4 weeks for IV antibiotics.

Lastly, I'll mention Ms. Luz...a little girl who has Pertussis, otherwise known as whooping cough. She's got the classic whoop at the end of these awful coughing fits. It's impressive to see the classic presentation of a disease, but at the same time it sucks b/c although she's on the right antibiotic it just takes time to get through the worst of it and even though her whole family should get prophylaxis they won't b/c there is no way to prove it's pertussis and the insurance won't pay for the medicines without proof. Sounds familiar...

January 10, 2009 Santa Clotilde

SENORA NELLY

I was on call the other night with Senora Nelly a tecnica (like a medical assistant) that has been working at Santa for 22 years. She is by far the best tecnica in the center. She knows how to do everything, knows where everything is, and the doctors often ask for her opinion during procedures. While we were sitting I asked her how she came to work at Santa and she told me a great story.

Sra. Nelly is from a comunidad (small town) about 3 hours from Santa by canoe. She only completed grade school because her parents did not have enough money to send her to high school. So at about age 12 she started working with her parents on the chacra (farm). When she was young she got pregnant and had her first son. She said that at first he was fine, but when he was about 7 years old she noticed that he ate all the time and didn't gain any weight. She had taken him to health posts before but he was always just treated for parasites. He then started to wake up frequently at night to pee. She had heard that there were some gringo doctors in Santa Clotilde so she decided to bring her son.

She said at the time it was just Padre Jack and Padre Mauricio. They saw Padre Jack and he asked them to stay the night so he could do some tests and observe the boy. He asked her to collect the urine overnight and in the morning the Father Jack said he had a pretty good guess why the ants were so attracted to her sons urine. They went on to diagnose him with Type I Diabetes and started him on insulin. They asked her to stay at the hospital while they started treatment, made sure he started to get better, and taught her how to give the insulin. The initial visit stretched into three months. She said that at first she would help clean around the center, but after a while she got bored and since the Fathers had no one else to help them she asked if she could help them give medications. She said, if they would label them, she would give them. They said yes. And then slowly she asked for more and more responsibilites. She asked them to teach her how to take blood pressures and she said it took her a while, but that padres were very patient and she learned. Finally, she decided she must go back to her village and help her mom back at the chacra...so she went with a cooler to keep the insulin cool and went back to working at the farm and selling their vegetables.

A few months later she got a letter from Father Jack asking her to come back to Santa and work for them. They would give her a position as a tecnica and train her. She said it was tough to leave her family, but knew there would be more opportunity for her and her son if she had a job that had a steady income. So she came to Santa and has been here since. She said that she learned everything from the Padres and reading the book "Where there are no Doctors". She now has 4 other children, 1 of which is now in college studying computer science.

She hopes the others will go to college as well, but it is expensive and she wonders what they will do with so much education. There are no jobs in Santa. She says that it is sad to see the kids finish high school and then have to return to the Chacra anyway. The main source of income for people here is agriculture. It's very small scale...pretty much enough to sustain yourself. The distance and cost to get to Iquitos are prohibitive for most people. The only other industry which is growing in this area is Petroleum companies and most are skeptical about their social and environmental impact. Even with these obstacles she still hopes for her kids to go to college in Iquitos, porque solo con hacerse uno profesional puede tener esperanza de dejar la chacra.

January 17, 2009 by Blanca Baldoceda

TYPICAL DAY

The town motor went out, so there

was no electricity for 2 days in a row.

I've been in Santa Clotilde for 1 week now and have just finished my first week of work at the health center. The Centro de Salud Santa Clotilde (CSSA) is the only health center on the Rio Napo. There are health post in other towns but this is the only health center. A health post is staffed only by a nurse or a medical assistant. CSSA therefore gets referrals from these health posts and patients will travel as long as 3 days by canoe to get here.

CSSA has a full staff, nurses, medical assistants, 4 peruvian doctors, a midwife, a dentist, pharmacy staff, and Padre Jack. Padre Jack, is basically, the jefe. He is a priest and internist by training, but he does everything...c-sections, osteotomies, dialysis. And he's been here over 20 years, totally committed to this health center, this community, and the region. As chief of the CSSA he also oversees the many health posts along the Napo River and coordinates vaccination campaigns to remote areas. The center has a procedure room, an OR, offices for outpatient visits, and a hospital with approximately 30 beds. Hopefully soon, I'll be able to upload photos.

A typical day starts with a run around the town with one of the other doctors, followed by breakfast and then it's bedside rounds at 8am. The rounds are very interactive and there is definitely an emphasis on education and wanting to learn what is being done by others, what is done in ideal conditions, and then what can actually be done here. They are constantly asking me what we would do in the states. After rounds we see patients in the consultorio. You see patients until 2pm and then your day is over. Occasionally you stay later if you admit a patient, do a procedure, or there is a delivery. Lunch is whenever your done with patients and then the afternoon and evenings are yours, unless your oncall. So, that's it....a typical day in Sta. Clotilde.

January 10, 2009 by Blanca Baldoceda

STAFF AT CSSC

Centro de Salud Santa Clotilde Staff

I'm on call again tonight, but it's currently pouring rain, so I should be patient free for a while. I've spent some of my first two weeks here trying to figure out how this health center fits into the bigger Peruvian health care system.

Santa Clotilde is pretty unique because it is a partnership between the Catholic Church and MINSA (the ministry of health). So Father Jack is the director of the health center but he is an employee of the church and not the ministry of health. This is huge, because it has offered Sta. Clotilde (Santa) continuity. My understanding is that for other areas of Peru, the directors of health care systems are often political appointees and so there can be a lot of turnover. The employees here are a mix of those employed by the church part of the health center, others employed by the MINSA part of the health center, and those given contracts by the local government. Not sure who's employed by whom, but it mostly seems to work. The medical providers tha work here come from all over Peru. There are 4 Peruvian doctors that work at Santa...none are planning on staying for more than a few years and none are from Santa. One of the docs is doing his Serum...this is a year of service that all doctors and nurses must do after they finish medical school. He is from Iquitos and is plans to go work somewhere else before doing a residency. There is another physician that is contracted by the church and she's been here a year and will likely stay another year, before she heads back to Lima to try and get a residency spot. The 3rd doc was contracted by the city council and has been here 6 months...he's not sure how long he's staying, he hasn't been getting a steady paycheck, which doesn't help. He also aspires to find a residency spot in Lima. The 4th doc is also from Lima and is on vacation right now for his wedding, but my understanding is he'll be here two years. Our midwife is contracted by the church and she's been here a year, but also plans to return to her hometown. All the docs say this is a great experience b/c you get to manage cases you wouldn't in a big city, but they all want, understandably, to be closer to home and to more opportunities for their families. It underlies how difficult it is to find physicians who are willing to stay in a rural setting without giving them some real incentives. I don't know how much the doctors make here...but it's not enough to compensate from being far from their family.

January 15, 2009 by Blanca Baldoceda