Leavin' on a jet plane.......

            Actually it was a float-plane, and it was quite an experience. We have been busy here in Santa lately as the patients have been very sick. We have not had a ton of business, thankfully because our acuity of patients is keeping us plenty busy. Earlier this week, Monday morning in the early hours a family brought their 6-month old son in with fevers. He had an abnormal neurologic exam with asymmetric pupils and seizures.  It appeared to us that he had meningitis. After trying to stabilize him with antibiotics, a blood transfusions, and anti-seizure medicine we realized he needed a CT scan and couldn’t wait. We called the insurance program in Iquitos to see if they could arrange an airlift. They were able to send a small float plane that landed on the river.

            I traveled with the dad and the patient. We boarded the plane, which had one small seat in the back where dad sat with baby in his lap. I sat scrunched up on the floor beside him with my stethoscope and array of medications. Not much room at all! We trolled around the river for about 15 minutes making sure we had a strip of river long enough and free of sandbars to take off, and up we went. In the plane it only takes 45 minutes to get to Iquitos. The plane was tiny and reminded me of the plane I was more than happy to jump out of in Hawaii when I went skydiving. However, I was now just praying this thing stayed in the air and no rain was between us and Iquitos, as I had no parachute. We did arrive safely on the river and took a small motorboat for about 10 minutes to the port, up 30 stairs into an awaiting ambulance. The child had tachycardia (fast heart rate) and a seizure on the trip and since there was not even enough room to hang to IV high enough I had to push fluid and meds into his other IV to try and slow his heart rate down and stop the seizure. I was able to look out of the window for about 5 minutes total during the trip. It is amazing to realize how remote we are, how much forest there is and how immense the rivers appear. In the distance you could tell where the communities are, as there were plumes of smoke arising from the trees from the cooking fires.  I most enjoyed seeing the confluence of the Ucayali and Marinon rivers forming the Amazon.

Arrival to the hospital was a frustrating and eye opening experience. The regional hospital is for those with the national health insurance. There is another national hospital for those with the other national health insurance (teachers, public workers, hospital employees). The best hospitals are the private expensive hospitals. As we entered we met our nurse, Elita who takes care of our patients in Iquitos. She is wonderful and is contracted by us to make sure patients can navigate clinic appointments, insurance forms and the hospital itself. She helped get our patient seen immediately in the ER and helped facilitate his care. I was amazed to find no doctors in the ER…..can you imagine if this were the case back home???? The doctor on call for the hospital also was nowhere close by and it is just me and the 2 ER nurses, who were helpful. However, they did not realize the gravity of the illness.

I spoke with the doctor on call who came in for about 5 minutes who said, “oh you have sick kid, let me write the orders and the ICU will come evaluate him.” I was asking him if we could intubate and start more anti-seizure meds. He said, “the ICU will take care of that, they should be here in an hour” Finally, Elita located a peds resident on the 3^rd floor and when she walked in she said, “we need to intubate.”  THANK GOD, someone who knew how to handle kids and knew where the equipment and tools were to take action. Together we put in a tube to the stomach, gave phenobarbitol IV for the seizures, a breathing tube into the lungs and bagged the kid for an hour before transfer to the ICU and a connection to the respirator. We then were able to get a head CT. Appears the child has meningitis and still not sure if it is bacterial or viral but he is receiving the right treatment. However, with seizures and high fevers his prognosis is not good. If he lives he is likely to have severe developmental delay.   However all is not lost, we did everything we had available, the baby is alive and both parents are in Iquitos with their child and they can make decisions on how to proceed. I am sad for the child and family, but he taught me how to get care in Iquitos. I now know I have to really stir it up, find a doctor and get things moving. I was a little overwhelmed when I arrived not knowing where to go, who was who, who to alert, etc. Now I will be a lot more vocal in every other transfer I bring to Iquitos.

In terms of the hospital it is 3 stories, they have x-ray, one CT scanner and a lab. They have an adult and peds ICU and floor beds. It is run down and dilapidated. They have two slow elevators, paint chipping off the wall. It looks like a public housing apartment in need of rehab.  It is amazing to me that the main hospital for a city of ~600,000 people has no doctors in the ER and the doctor on call usually leaves after morning rounds to go work in his/her private clinic to earn more money. I am also astounded the people don’t speak out in masses to the local government, but I guess when you don’t know what care is like on other parts of the world, or Peru for that matter, you come to think the care provided is the norm. I learned we need to do as much as possible in Santa Clotilde, because the help in Iquitos is not adding as much as I had thought to patient care. That being said, some of the doctors are very good including Dr. Camilo Ruiz who is in the ICU and did a year of work in Santa Clotilde with Padre Jack several years ago.