Doctors in a foreign land

     As Antoinette and I continue to work hard, I just wanted to reflect on our time here. I sit to write and plan on just letting whatever comes to my head out on paper. We are leaving here on Friday morning for our firstvisit back home to Chicago, we will take the boat to Iquitos where we may have a minute to breath, but probably not too much rest because we will have to transport a patient and make sure they get care in the hospital and also need to look into things like lab machines that may help improve our patient care up on the river. We then fly to Lima on Sunday and have a red eye flight on Monday night arriving in Newark early Tues morning before arriving back to Chicago for the month.
     In our time here we have begun to establish some relationships with our co-workers and others in the community. We have been comfortable treating diseases that were very unfamiliar and anxiety provoking our first few weeks here such as snake bites, dengue fever and malaria. We also are more comfortable managing illnesses without the elegant exams and tests we were very accustomed to back home. We have become frustrated with the red tape and paperwork required here in Peru such as the insurance forms and all the documentation that the government requires. Padre Jack refers to it as "their insatiable hunger for numbers" which in the end get filed somewhere in Lima and serve no purpose because nobody does the epidemiology or usues the numbers for a good use. They are an necesary evil because we need to get as much from the national insurance company for what we do; as many patients cannot pay much more than the fee to have a consult, our clinic needs all h income we can generate. The difference our budget from income to debt is made up by the donations mainly from the Canadian Oblates and US Norbertine abbey in Wisconsin. Thus, Pango (a civil association) was formed to keep funding, projects and healthcare going on the river as inevitably Padres (Jack and Moe) will at some point depart for home and hopefully have nice relaxing time after their service for some many years here in Peru.
     We have done some interesting things as I look back it is pretty amazing to accomplish/perform this high quality medical care in the jungle and it can all be attributed to the drive, ingenuity and passion that Padre Jack and Moe have had over the last 25+ years. One example is c-sections, i even assisted Antoinette on one a few weeks ago. Can you imaging operating with your spouse??? It went very well. We have done spinal anaesthesia, spinal taps, incision and drainage of abscesses, intubations, given supplemental oxygen for pneumonias, IV antibiotics, sutures of big wounds, pre-natal ultrasounds, liver/gall bladder ultrasounds, dilation and curretage after incomplete spontaneous abortions, emergency transports to Iquitos. We even attempted peritoneal dilaysis in the last moments of one patient's life as a last effort to save her. There is more to do and more we can help with, and we are inspired everyday by Padre Jack, Dr. Juan Jon, the staff and all the students and volunteers that come through and ask us the challenging questions that help us all learn together.
    Our one patient Hucielita who was an 11yo girl with renal failure will forever stick in my memory. She came to clinic shortly after we arrived as a 10yo girl. Her mother told me "her face has been swollen for the past 2 weeks" which is a textbook presentation for a renal problem. So i checked her urine and labs to confirm glomerulonephritis. In the hosptial she celebrated her 11th b-day, we sang to her and Ant and I gave her a sucker and a beanie baby as a present. She improved with IV medications and blood pressure medications and we sent here home with the thought that if she does not improve in 1-2 months with her blood pressure or protein in her urine she will go to Lima for a renal biopsy. She came back for an outpatient follow up with improved blood pressure and less protein in her urine. Her chronic anemia made us think maybe chronic renal disease, but still no signs of alarm. She came back once more again improving, but we started to discuss a transfer if the next visit she did not resolve all of her symptoms. Her transfer is not an easy thing, we have to fill out papaerwork, find money for the trip for her and a parent, have the hospital in Lima accept the patient and then convince patients to travel. Often the patients have never left the 5-6 hour radius of their home town, seen the city, let alone flown in a plane. They all worry about not being able to pay, which is legitimate because not one person on the river has enough money to get to Lima on their own. When she came back 5 weeks later it was 3am and Padre Jack was on call and woke me up for a consult. She was grossly fluid overloaded and in respiratory distress. She was having acute renal failure likely in the setting of already damaged kidneys. She was not stable enough to transfer by boat to Iquitos. We did our best here, but her kidneys shut down in front of our eyes. We even arranged for an rare airlift to Iquitos, but 2 days of rain cancelled the flig each day as it was too dangerous to fly and land on the river in the weather conditions. We had her on diuretics, dopamine, oxygen and even tried dialysis. Shortly after midnight she coded and died. It hurt, very sad case. This was a very happy smiling girl who lives in poverty with loving parents and a chronic disease. She succumbed to her disease despite our efforts, a disease that would likely not have killed her in a developed country. Her father was very appreciative and thankful for our efforts, he took her home that night to bury her. Mom was understandably upset and angry that she lost her daughter. It was a sad day for all of us.
    The diseases here interesting to say the least. I will list what we have seen, and for those not in medicine you might be bored or cannot pronounce half the diseases but here it goes: malaria vivax and falciparum, dengue fever, meningits with brain abscess (confirmed on CT in Iquitos), premature babies, pneumonia, asthma, pyelonephritis, snake bites, cerebral malaria, glomerulonephritis, BPH, vulvar cancer, chronic pressure ulcers, pterygium, acute coronary syndrome, diabetes, congestive heart failure, persistent ductus arteriosis, hydrocephaly, metastatic cervical cancer, tuberculsosis pulm and in the GU tract, lymphadenitis, Hodgkins lymphoma (diagnosed on our LN biopsy and transferred to Lima for treatment), HIV, toxoplasmosis, necator americanus, ascariasis, trichuriasis, Hymenolepsis nana, Strongyloides, Leischmaniasis, hepatis B, cirrhosis, bleeding esophageal varices, congenital fibrotic bands causing bowel obstruction, cleft lip/palate, failure to thrive, supracondylar fracture, fractured mandible, mastoiditis, LGV from chlamydia, rheumatoid arthiritis and last but not least Antoinette just called me for a consult on a 10yo boy that fell and now has a scrotal hematoma...ouch. Well off to read more on the management of scrotal hematoma. Life is never dull here in the jungle, happy to be doing what we are doing and learning so much. Also glad to be coming home for a bit, for a break and see friends and family. The batteries need a little re-charging. See you soon.