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 3rd 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. 

Happy 4th of July

Homemade pumpkin pie by Liz for 4th of July and Nathan's Birthday
And Happy Birthday Nathan!! Nathan is 30 years old today! He was first here at Centro de Salud Santa Clotilde as a patient 6 years ago. He was traveling on a boat from Ecuador Iquitos and was blinded by a terribly eye infection. He made it by boat to our port and was guided by staff to the hospital where diligent care with antibiotic eye drops restored his vision. As a thank you, his mother Katherine Kaplan, an OB/Gyne and his father Dan Schenkman a veterinarian have volunteered here with many of their doctor friends every spring. Nathan we were in search of translators for the big International Medical Relief health fair that takes place at the end of this month. He agreed to come and translate for us... and to spend a few extra weeks helping out.

Nathan lives on a farm in North Carolina. He raises chickens for eggs, grows in own food in a big garden, tends to many fruit trees, and also happens to be an amazing chef! He has been cooking delicious dinners for us daily. Nathan goes with the flow, doesn't get riled up, is a really hard worker and always jumps in were needed. He sat with our staff last night telling jokes until the power went out.
He is respectful, energetic and great to have as a housemate. We're trying to convince him to stay here, but he has strong aspirations to go to medical school, where I know he'll succeed in all respects!

Big Wooden Boat

Top of the boat... big enough to pitch 5 tents!

This is amazing. Neo and Marcielo own this huge wooden boat. Marcielo is one of the only people in town who sell gas. He uses this boat to transport barrels of gas from Iquitos to Santa Clotilde and utilizes both the flat top and spacious inside. They have offered to donate the use of their boat to International Medical Relief, an internationally known organization who brings health care to those who need it most. International Medical Relief will be here from July 20th to the 28th and will travel upriver to Angoterros and down river to Mazan/Iquitos where they will offer free medical and dental care, free medications, reading glasses, and community classes.


Boats, mototaxis, and stretchers

The hum of the motor from the back of the rapido, loud festive music blaring in front, and the windows rattling from the temped breeze blowing in feels surreal. Alicia and I are returning from an emergency transport to Iquitos. Two patients had arrived to Santa Clotilde the day prior in critical condition. Jany is a 49 year old woman who arrived so weak she was unable to walk, and bleeding from her gums and the site of an injection that was administered last week. She had severe anemia, probably from chronic blood loss. We diagnosed her with probable sepsis and disseminated intravascular coagulation and she was in a coma by the time we left Santa Clotilde. Carola is a 48 year old woman who fell from 2 meters on her head and broke her neck. When she arrived she was paralyzed from the chest down and had severe tingling and pain in her arms. Although she could move her hands, she had a hard time with small movements.
We traveled 4 hours by boat to Mazan, then put them on mototaxi’s and brought them to the Centro de Salud in Mazan. There, we gave some antibiotics, ensured they were stable, and drove another 15 minutes on mototaxi to the port on the other side of Mazan.  After 3 hours in Mazen, we loaded the stretchers onto the boats again and headed to Iquitos. In Iquitos at the Nanay port, we carried the stretchers up to the street and waited for the ambulance. It arrived but had enough room for one patient only. We took Jany first since she was unconscious, and then the ambulance came back to pick up Carola. We had in depth discussions with the internist and spine surgeon in Iquitos regarding diagnosis and management of our two patients.
We also stopped to visit the 6-month-old patient Jordan with seizures and meningitis who Brian had airlifted to Iquitos two days prior. He was intubated and sedated, but stable. His mother, who had been weeping uncontrollably as the plane took off with her husband and only child, had found the strength and hope to stand strong for her son. We were talking and laughing about everyday things and it was really nice to be able to keep her company for a while.

After ensuring that they were stable and well cared for, Alicia and I headed back to the Vicariate where we spent the night. It was a restful and rejuvenating 8 hours of sleep after a day of boats, mototaxis, and stretchers.
7 July 2012