Crash

Inez arrived at 9pm with labor pains. She had no prenatal care and didn't know how far along her pregnancy was. By ultrasound, she measured 30 weeks which is one and half months PREMATURE. Her cervix was not opening, but we gave her some IV fluids and steroids to mature the baby's lungs. We don't have surfactant here (helps premie babies breath) and we wanted to give the baby as much time as possible inside mom. The next morning, she started having strong labor pains. Within 30 minutes she was fully dilated, which isn't surprising being that this was her 8th pregnancy. Dr. Juan did an exam to check for dilation and realized that she had a CORD PROLAPSE... the cord came out and the baby's head was compressing it against the pubic bone. "There is a pulse" he said. Seconds later as we prepped the OR, "there is no pulse." We delivered a live baby under LOCAL ANESTHESIA, but the baby was very preterm. I put lidocaine in the skin, and when there was a delay in obtaining more lidocaine, I just made two cuts and pulled the baby out. Mom was given Ketamine immediately and thankfully doesn't remember being opened without much anesthesia. Dr. Juan was scrubbed with me and multiple times he reminded me to breath. Brian and Jason Howell worked on the baby. She was having trouble breathing so Brian intubated him. Lili the nurse started a peripheral IV and the baby got a bolus and then dextrose and antibiotics. For two hours we helped the baby breath with an ambu and a little bit of oxygen. Meanwhile, we were trying to coordinate getting him to Iquitos where they have surfactant and a ventilator. The 5 hour boat ride + 10 min mototaxi + 1 hour boat ride + 15 minute mototaxi (normal mode of transportation) was out of the question, so we called the military to ask them to transport the baby by helicopter, which would take only 2.5 hours. After over two hours, the baby decompensated, the heart rate and oxygen level dropped, and the decision was made to remove the tube and bring her to mom. We don't know why...maybe pneumothorax? It was a sad day. Mom is doing well. She went home today (across the river) and will be back in a few days to remove her staples. Pray for Inez and her family and baby Julia.
Toni
27 March 2012

Our new puppy

As most of you know Antoinette never wanted to get a dog or any animal for that matter. However, since being in Peru she has grown accustomed to all the animals around, namely the pregnant cat Sabrina, several dogs and roosters. It was even at the point where she made a small little area for the cat to sleep on and left out a bowl of milk for her at night. Antoinette even thought about raising one of the kittens. Sabrina delivered over a week ago but we have not seen a trace of any of the kittens. Our friend Victor Hugo had a litter of 10 puppies from his dog China a mix between a pit bull and german shepard. When I asked if we could have one he said sure, even though he thought about keeping a male dog that could go hunting with him, he was happy to give us one of the puppies. When Antoinette went up river this month for 10 days (Victor went as well) I thought it was a good time to retrieve our puppy. He was about 6 weeks at the time, which is usually a little early to take away from mom, but his mom still wandered around at night and he would latch on 2-3 times a day to feed from her. He whined at night and liked to poop on the floors, but if I let him out enough he did not have any issues. He sleeps on our patio now and is growing well. I de-wormed him once with the pills hidden in a piece of hot dog. When Antoinette arrived she was happy to play with our cute happy little puppy, however I am still relegated to doggy dookie duty.

We named him Wookie (still not sure about the spelling), which is a word in the local Kichwa language that means brother or friend. When I asked my nephews Caden and Henry via skype what should we name hime, they came up with River Monkey, so that is what he is referred to back home. All the locals seem to think Wookie is a great name, and he will wander around the hospital and clinic when we are done seeing patients in the afternoon. The staff and patients are getting to know him and the kids love playing with him.

Dia 2- Rumi Tuni

April 1, 2012

I am tired. We worked in Rumi Tuni today, one of the bigger towns we’ll vaccinate. The clinic structure is beautiful, but inside is sparse. We didn’t even have chairs for the patients to sit on today. From 8am-5pm, I saw over 30 patients. Seeing Mari was a highlight today. She is 3 years old and had a congenital bowel obstruction and 8cm of small intestine removed. After her incision stopped draining stool, she was transferred to Santa Clotilde where we watched her gain weight for a week before we sent her home. Today, she came in with a fever and cough. Her complicated surgical history and skinny little body worry me a bit. She may have nothing more than a cold, but she got ibuprofen and erythromycin and I’ll see her in three days when we travel to her town. I also saw Valentin and his wife, who brought me two eggs. He was hospitalized in Santa Clotilde for severe hypertension and possible stroke, and sent home with a diagnosis of hypertension, Parkinson’s, and bells palsy (that he’s had for decades). His dizziness limits his functioning and that is his main concern. The hypertension and tremor don’t matter much to him. Again, I saw a handful of prego’s who deliver at home with their mother in law. It would be great to have group prenatal classes here, where the woman brings the person who will attend the birth, and teach them to recognize signs of alarm.With the scarcity of furniture and millions of mosquitoes, I wouldn’t think to ask them to deliver at the health post until/unless some big changes are made. By the end of the day, I just wanted to speak in English and not have to think too much. Luckily there is a phone here, so I did call Brian twice today. People here have asked, “tiene pena?” aka “are you sad” being away from Brian. While absence makes the heart grow fonder, 10 days will be a challenge.

For lunch (at 5pm) Rober Figueroa made a delicious big fish grilled in a banana leaf with some spicy cocona salsa, plantains, and rice on the side. It was dusk and within 10 minutes, the room filled with mosquitoes and you could literally hear the humm of mosquitoes coming out to graze.

I’m back on the boat, which has no mosquitos. The generator is running to power the three high-efficiency light bulbs along the ceiling. I am tucked away in my bunk surrounded by our green mosquito net (generously gifted by Dea and Jim for Christmas). My eyes are getting heavy. We will pull out of RumiTumi tomorrow morning and be awoke by the sound of the motorist starting the engine and water rushing along the sides of the boat, all while tucked away neatly away from the mosquitoes with my eyes closed.

Toni

The Journey of a Cedar tree

It came as a surprise to me how much deforestation and illegal lumbering that occurs here on the Napo River. This is something I never thought about prior to my arrival here in Peru. One often hears about how the rain forest is being wiped out, well let me tell you a little more. Precious wood such as cedar and mahogany grow here in the rain forest. Obviously people pay top dollar all over the world especially the US to have a nice wooden table or cabinets.

The story begins, as has occurred over hundreds of years, with the poor being exploited without their knowledge. The local people know where the trees are and a “padron” will come speak to a small group in the communities or have someone gather up a crew and offer them a set amount for their work over a few months. There is no contract, only an informal agreement. Some of these workers come up river from Iquitos to work as well, not just locals. The lumber men then come up the river after it is gathered and take the wood, often telling the workers they will pay them after they sell the wood in Iquitos. As you can imagine they often never come back to pay the workers and walk away with hundreds to thousands of board-feet of wood. In the US, one board-foot of cedar costs about $15.00 for you or I to purchase. The workers have no rights and they cannot complain to anyone because there was no formal contract. They also have no idea how much the wood is worth. The workers if they do get paid get 1 sole per board foot or $0.38. The wood/logs gathered are pushed down the river by a boat. They have to pass a police checkpoint and right next to the port in Iquitos is the Naval base. None of the people have permits to lumbar in the region, but a small bribe and nobody sees anything. The wood is then cut in Iquitos and the lumbar sold to dealers. There is never a new tree planted and no re-forestation projects to prevent the loss of the rain forest.

Furthermore lumbering is very dangerous!!!!!!! We see accidents almost weekly and last week 2 men died, one whose brother Victor we know very well. Victor works here for the clinic has been working with Toni on the vaccine trip. It was a very sad day as the entire vaccine group went to the small town for the funeral so Victor could attend and see his brother one last time before the burial. 3 weeks ago a purchaser from Iquitos brought his adolescent son along to help out. As their boat was pushing the wood down river, there was a log-jam and their boat hit the logs and flew on top of the wood and flipped over. His son’s head went right into one log and he had a deep massive laceration on his scalp that took me an hour to sew back up. If he had lost consciousness when the boat flipped he would have drown in the river. The dad also has no formal contract and the lumbar companies do not pay for health care if there are any accidents. There is no training for the workers, no hard hats, nothing. There are probably 1-2 deaths a month from trees falling on people. I thought; how can you get hit by a tree? After helping carry the cross made out of 2 logs for one station on Good Friday this week I can now see how heavy a large tree would be, if you take into account the size of the tree, the fact that there are several surrounding trees and large branches that never get cut off first the risk is tremendous.

I am not saying to not buy lumbar, but make sure when you do ask if it is certified lumbar. Certified lumbar should have a stamp on it indicating its source or where it came from. Certified lumbar means that the companies have a legal right to cut the lumbar, their workers are trained and have contracts and they re-forest the areas that they take the lumbar from. More information can be found at illegal-logging.info.

Brian

12 APRIL 2012

Vaccine Campaign Day 1

29 March 2012

It’s Friday and I’m sitting in my bunk, in our wooden boat. We took off from Polako’s balsa at 6 am today. Brian, Padre, Laura, Bill and I were waiting for the boat to arrive. We saw a woodenboat with a straw roof float by, as it was passing us, it made a U-turn and started approach. “Could all 9 of us be traveling in that?” I wondered. I had seen this boat before and wondered how people could possibly travel in it. It seemed very narrow, maybe 4 feet wide, and I imagined a board along the length of each wall that might fit 8 people it they sat squished together in the dark damp vessel. I was shocked when I boarded. It was enormous inside. The boat is about 8 feet in width and dividing the front and back it small kitchen, complete with propane stove and shelves stocked with food. In front, there are three foot wide benches on both sides with two big coolers full of vaccines and another full of medicine. A pink pasley hammock hangs in front of the door, which remains open for our entire journey. Behind the kitchen, there are bunks with rolled mattresses on both sides, where 8 can sleep very comfortable. Further back are another set of doors, and hidden from sight behind two barrels of gas is the motor. I quickly get used to the hum of the motor and water splashing on either side of the boat. All the water I drank was catching up to me. I ventured to the bathroom, beyond the motor in the back of the boat. There are two narrow boards on either side of the motor the shimmy back on. The motor with its loud hum churns the orange glowing water below. One wrong step and the motor eats you. I safely make it to the bathroom, and I find a toilet seat on a bucket that falls right into the river. The driver takes note that I’m back there and slows the engine to relax the river water under the toilet, which keeps my bum dry. Walking back to the front of the boat, I notice the intricate handmade roof of oja jirapay- palm leaves twisted around a stick. This roof will keep us dry and cool for our 10 days up river.

The sights are beautiful. The dark water is rich in nutrients (and mercury and lead) and the green walls of jungle flora on either side house thousands on animals and insects, many have yet to be discovered. One of those animals is the “motelo” and happens to be our dinner tonight. This large turtle was sold to us by a family in Sumallspa. As we head up river, we stop in each community we plan to vaccinate. In Bandeja Isla we ran in to a large extended family with at least 10 kids running around. They we walked into their chakra (field) where we saw a sajino named pancho, a pichiquo (tiny monkey), a turkey, dogs playing among the yucca, peppers, and peanuts.

Our first destination was Caja Marca where everyone got situated. We set up a table for Victor Hugo the renaissance man who played dentist today. Limber and Jisseli were in charge “programas” which vaccinates kids and pregnant women and follows childhood growth and development. Bill had his computer to see if patients were registered with SIS, a local public aid, and if not, he instructed them how to do so to get discounted meds and care. Manolo had his solar powered microscope and was able to do Malaria smears, stool studies, and testing sputum for tuberculosis. Almost everyone has ascaris and trichuris (worms) and we only had one patient with giardia. No one had malaria. Neo helped fill out SIS forms and was the pharmacist for the day. I set up shop in a classroom where I diagnosed lots of parasites, headaches, low back pain, common colds, and two sisters with what looked like cerebral palsey- walked on their toes, developmentally delayed, spastic… but to have CP in both sisters with an uneventful birth history is maybe less common than a hereditary muscular disease. There is no physical, speech, or occupational therapy here so the diagnosis is unlikely to lead to clinical improvement. I saw a handful of pregnant women. One has 10 kids at home and is on #11. Another is pregnant with her second child but has a transverse lie at 28 weeks… hopefully the head moves down or she may need to travel to Santa Clotilde for a Cesearian Section. Another had 10 but 4 drowned in the river. She looked sad, and her story explained why.

We continued boarded the boat and headed back downriver to Sunullacta… and yes, one of God’s creatures was served up for lunch. The motelo turned into soup. It really was delicious! For some reason, a turtle is much more appealing to me than cute fuzzy animals and monkeys. We stopped at the first sight of an orange tree to buy oranges, and picked up some puhuayu and passion fruit while we were there, and the family bought some rice from us. The barter system is commonplace and very convenient.

We had discussions on what we might do differently next trip and how we could streamline data entry- instead of using a paper book, we could use an Excel spreadsheet that would allow us to filter and pool data for quality assurance. We have a couple options for systems, but we’ll have to discuss with someone who has more experience than Bill and I.

Sunallacta has a similar feel to Caja Marca. I learned that neither of these towns have active health promoters. One moved and the other wasn’t empowered because they lacked continued trainings. I also confirmed what I learned in Santa Clotilde, that 90% of babies are delivered at home by a family member with NO formal training in labor. I would love to identify experienced members of each community and provide basic trainings on how to recognize signs of alarm and how to deal with emergencies. The multigravid patient I spoke to said that there had been no bad outcomes in Sunallacta, although there was a women in Caja Marca last month who went into labor with a transverse lie and the arm came out, and the baby died by the time they arrived in Santa Clotilde. It takes two days to get to Santa Clotilde on pecke pecke, the local mode of transportation. A trained person may have been able to save the babies life.

Sunallacta we headed to Rumi Tuni, where I am sitting now in the health post. After spending and hour filling our paperwork for insurance, I decided to type while I charge my computer and camera. There is otherwise really no electricity, although we could light the boat with the motor if we decide to do so. I walked into the sparsely furnished clinic to find swarms of mosquitos, and on a happy note an actual shower! I’m fresh and clean and covered from head to toe I clothes. I learned on my last three day trip up the Tambor River to bring “mangas largas”- long sleeves. The heat is tolerable, but the biting flies and mosquitoes are not. I’m in my cozy black pants and green t-shirt with Brian’s long socks and long sleeve white pullover, and my flip flops. While style is never really my main goal, it’s nice that here I have nothing to be embarrassed of since the main objective is just to cover your body.

I have yet to do laundry. We wash in the dark brown river water, which I’ll have to do tomorrow… or maybe pay Julia our cook to wash while we’re working? What a great idea!

Toni

The answer is.....Leishmaniasis

We posted a picture a while back showing a leg with several ulcers on it and asked for the diagnosis. Alex Rankin aswered correctly. The genus Leishmania is a parasitic disease transimitted by the bite of a sand fly. There are several species of leishmaniasis that casue cutaneous, mucocutaneous or visceral disease. Thankfully we do not have the visceral type in Peru. Treatment is a dose of IV medication daily for 3 weeks

Look for more quizes later when we have more interesting pictures

Brian

07 Abr 2012

The best part of waking up……

Thanks to Dan and Katherine we now have excellent coffee. They were reading our blog and saw I was surviving on instant coffee and they came bearing gifts: a French press, coffee grinder and 3 bags of coffee!!! So who are Dan and Katherine anyways? Well it is quite a nice story, and you can read Fr. Mauricio’s version on the PANGO website (www.pango.pe). In short, their son Nathan was a tourist coming down the Napo river several years ago from Ecuador and no one told him wearing contacts several days in tropical weather was a bad idea and he developed a corneal ulcer. The boat he was traveling on stopped to make sure he received treatment here in Santa Clotilde, and Fr. Jack took care of him, called his mother and he was flown home and followed up with Dr. Rebecca Bartow an ophthalmologist. Dr. Katherine Kaplan was moved and grateful for Fr. Jack’s care that she offered her expertise to Santa Clotilde and she has been trying to make the trip annually since.

In March she, her husband Dr. Dan, her son Nathan (medical school ), her colleague in OB/GYN Dr Joe Welton, Dr. Rebecca Bartow (ophthalmologist) and her husband Dr. Tom Bartow(rheumatology) all came to work for a week. I unfortunately was working up in Angoteros at the time, but it was a success. Several patients were able to have hysterectomies, tubal ligation, joints injections, and pteyrgium operations during their week here. The team put in a lot of effort and even broke in the new operating room and delivery room.