6th Grade Graduation

Happy 6th Grade Graduation! The largest class of 102 kids graduated on December 9th. All graduates wore elegant ivory dresses with fancy silver heels or white shirts and a tie. For the ceremony, all the females are paired up with a male and they danced together the entire evening. They have "fill-ins" if there is an uneven number of males and females, and these kids wear different color dresses or shirts. There was a "godfather" of the ceremony, a doctor from the city, who financially supported the party. The kids desks and chairs were pulled out onto the sidewalk between two school    buildings and they were all dressed with white tablecloths. Families chose a table as they arrived. Each family brought their own pitcher and cups and filled up with juice in the kitchen before the plate of chicken, rice, potatoes, and olives were served. Each table also received a couple bottles of soda and beer, and then for dessert a "brindis", or alcoholic toast with coffee, milk, sugar, and aguardiente (local potent sugar-cane alcohol that tastes a little like tequila).  Seeing adults sit on little chairs with little desks made me laugh, but that is how things are done here. While graduates' names were being called, they stood in two lines of partners and advanced over the sidewalk dividing the grass. Meanwhile, the "security guards" were chasing down dogs who snuck in to the party to kick them out. Wawki (our dog) managed to get in a couple times but was quickly hunted down. Dinner was followed by disco lights and really loud music, and almost everyone danced. I showed some of my american moved and had everyone laughing. Brian and I were invited by Victor Hugo and Leynis who's son Victor was graduating. We knew that of people and had a really fun time dancing and sharing stories. The festivities lasted six hours, but we didn't make it to the end and headed home. 

End of the world.....really????

           Well if the Mayans were right then Antoinette and I are separated by 6 hours of river as I traveled up river to the community of Angoteros. I will be working in the health post all day today and then, the reason I came up, a meeting with the local authorities to plan for the inauguration of the new health post. On a side note I believe the Mayans never really said it was the end of the world I believe they felt it was the end of an era and the beginning of a new one, it was media and crazy people that said it was the end of the world, not the Mayans.
            Angoteros a community very native, a group named the Kichwa who have their own language, which is very difficult and of which I know about 8 words.  They are a quiet group and their elected leader the Apu is an older man, who also is of very few words even though he knows several languages and has traveled to several South American countries. There are some very beautiful aspects of their culture and some very ugly aspects. They continue their traditions, dances, teach their native tongue in the schools, but they also have an astounding amount of alcoholism and domestic violence. To an outsider gringo like me it is a difficult life and there seems to be lack of hope. There has been a lot of oppression and discrimination towards the people of the Amazon, most obvious starting at the turn of the century during the epoch of the rubber barons or epoca de caucho (rubber) y los caucheros. Several communities were enslaved, people chained together, taken into the jungle and forced to extract and carry the rubber to boats waiting on the river. Since then the government continues to ignore their rights, poverty and difficulties with a system designed for those with birth records, DNI (equal to a social security card), etc. These people do not have the funds to go to Iquitos to get their DNI paperwork filled out and then wait a minimum two weeks for it to get processed, where do they stay? what do they eat for these 2-3 weeks? Then to get social programs such as health insurance you need to have this DNI, to apply for the DNI you need your birth certificate, where do you get this in the middle of the jungle when you deliver at home??? We offer this service as the health network but many do not come in for several months and the same government states you need it filled out within 7 days of birth. For this reason some birthdates are not too accurate.  Next the government here might look around at other countries and maybe just give them money and a tiny plot of land where they cannot live the lives they are used to and tell them they can build casinos to solve all their problems, that seems to work well for native communities!
            In terms of the help given over the years by missionaries and NGOs it has not helped the long-term situation a whole lot. Over the years the people have grown accustomed to receiving everything for free without offering anything in return nor have there been efforts to create programs of sustainability. The people feel if they are going to help the church, NGOs, etc that these same groups will pay them as they had in the past. That is one of the dangers of just giving money, if no system is left in place then when the money stops, the people are right where they began. For example the two nuns in Angoteros cannot even ask someone to carry up a bucket of water from the river without them asking for money in return. It would be like asking to borrow flour or 1-2 eggs from the neighbor and the neighbor always saying sure that will be one dollar.  I am hopeful for the future of the river as the priests, nuns and now the health network on the river are working towards change in the people, a life of collaboration and partnership, not just of donor and recipient.  This may take 1 year, 5 years or 10 years, but we are moving in that direction and if we can instill this ideal in the younger generation than we can effect change and a better future.

written on 21 December 2012

Cleft Soft Palate

Patient transfer to Iquitos

I am typing on the rapido boat to Mazan, a 4 hour trip downriver. I have an elderly patient at my side along with his 2 sons. He is an elderly gentleman, who unfortunately fell last Sunday from the raised platform in his house from a height of about 6 feet. On arrival to centro de salud 2 days later during Toni’s call he appeared dehydrated, slightly agitated and feisty. All one had to do was look at his leg to see its positioning and swelling to know he broke his hip, or more accurately the neck of his femur. He is not a candidate for surgery due to his age, functional status and other medical problems.  This “abuelo” or grandfather has a large family, he had 11 kids, 9 of whom are still living . Most are in Iquitos but some still in the small town of San Jorge a few hours up river from Santa Clotilde. After several family discussions they wanted him to come to Iquitos for and x ray and an attempt at a reduction and stabilization of the bone, unfortunately none of this will likely change the consequences of the fall. He is likely to be bedbound and never walk again.
            No one really knows his true age as 7 family members all told me a different age between 87 and 102.  They also told me his oldest son is in his 80s, so that makes him close to if not 100 years old, the oldest person I have seen on the river. A majority of this region was Ecuador last century so some of these older patients were not actually born in Peru, however they, “never crossed the border, the border crossed them” as they say. 
We arrived at the hospital just fine and I ran into another patient who was being admitted. He had been referred, as an emergency case one week ago, but on arrival to the ER they examined him and deemed him not an emergency and discharged him as his exam was stable for them. He has since worsened, which is not a surprise to me and is back with fever and belly pain, he had a diagnosis of cholecystitis (inflamed gall bladder) with us and that is why we transferred him to Iquitos. He is now being admitted and examined later by the surgeon. The hospital is busy and the medical strike is over, so now we can get x-rays and send patients who need further exams, operations, radiology and labs we cannot do in Santa Clotilde. Hopefully by the end of 2013 we have our x-ray machine up and running, which will cut down some costs of transport and give us another medical specialty to learn and understand: radiology.

written 13 Dec 2012 

December 1: World AIDS Day

To honor the lives that have been taken by HIV
To increase awareness of HIV disease
To improve access to treatment
To promote prevention of transmissible diseases
Getting to ZERO new HIV infections

We celebrated World AIDS Day in Santa Clotilde with education and empowerment in the high school, skits, a parade, and free HIV screening. To our surprise, 2 of 30 patients were positive. In our small town of 6000, HIV in on the rise. Our midwife Blanca called an emergency meeting among some of our staff members to determine how we will proceed. Currently, if a patient is diagnosed with HIV, they need to travel to Iquitos (7 hours away) to get there basic labs, CD4 count, viral load, counseling, and medicines. There follow-up which ideally is monthly then every 6 months is also in Iquitos. Being that we have 40 patients diagnosed within Santa Clotilde and our satellite clinics, our goal is to be able to provide these services here at Centro de Salud Santa Clotilde. We have most of the necessary equipment already, but we need to find funding to buy the reagents and other materials and coordinate with the regional health office in Iquitos to be recognized as an HIV provider.

Thank you to our Midwives Blanca and Carmen and the dozens of other Centro de Salud Staff members who participated in World AIDS Day!

Extermination Team

Last night the lights went out at 11pm and I laid down in the pitch black call room, and I heard something flapping.. a bug.. but it was pretty far away. Then I heard it above the bed, high up close to the ceiling. So I covered my head with the sheet and just tried to sleep. But then it got REALLY close, and as much as I just wanted to sleep, I freaked out and threw the sheet off me and ran out of the room.

I ran into the laundry room where the two nurses and the night watchman Leonario were, and I told them that I was just going to sleep upstairs in my house... it's literally a minute away if you run up the  forty steps. Intead of conceding and being okay with me going home, they all stood up, armed themselves with their flashlights, and the extermination team marched to the call room. There it was, this sort of pretty brown spotted butterfly on the wall next to the bed. Leonario dutifully walked over and squished it with a stick, and it fell to the ground. Then I went to bed and slept peacefully until I was needed again in the hospital.

1 Dec 12


Mame is a fruit that blooms three times a year, and we're currently in the middle of a harvest. The world smells just like an apple orchard in autumn right now because we have three expansive Mame trees between clinic and our home. The fruit falls and starts to compose and smells just like cider. Kids are as agile as little monkies and climb the trees, managing to avoid getting bit by the colonies of ants that have made the trees their home. They down fruit by the dozens. The fruit makes great jam and another dish that tastes like apple pie filling, complete with clove and cinnamon. The fruit itself taste a bit like a washed out, cottony apple, but pleasant when chilled on hot day. All the little kids waiting in clinic chew on Mame that has fallen from the tree, and if they always ask permission to take mame or mango or papaya that grows nearby. They are very considerate and very happy to fill their bellies with such yummy God given goodies!

Happy Thanksgiving

Nothing like Liz's homemade pumpkin pie and Anita's chicken to top off a delicious Thanksgiving meal! With Brian on call, we managed to eat and relax for an hour or so before he was back to work. The stuffing, mashed potatoes with imported brown gravy, and string bean almondine were delicious!! We should definitely add stuffing and canned pumpkin to our wish list!

We were reminiscing about the Medernach and Lullo traditions and the yummy food that those back home were undoubtedly sharing.

We give thanks for our amazing family, friends, and coworkers for being so supportive and loving to us and each other. Have a blessed day!


Phlyctenulosis is a hypersensitivity reaction of the cornea to toxins. The most common cause of phlyctenulosis is a staph. BUT, here in the jungle, tuberculosis is alway high on our differential until proven otherwise. This kiddo came in with a red eye and little pustules where the brown iris meets with white of the eye. They responded quickly to Gent drops. PPD negative.


9 year old girl fell and came in with a purple swollen elbow. Can you see the fracture?

Sting Ray Stings!!!

More painful than a snake bite is the sting of a ray! She was wading across the stream to leave her son with her relatives and a piercing bolt left her speechless. One week later, the area on her heel where she was struck is healing nicely without signs of infection, but the pain brought her back for more ibuprofen.

Guess the diagnosis- lumbar X-ray

29 yo male with severe unintentional weight loss over months, cachexia, fevers, and a draining fistula in his flank... Transported to Iquitos for an Xray. Who knows the diagnosis?

Hormiga Curuwinsi

Miguelina: Yes, doctor. My husband eats them fried
Toni: But don't the legs get stuck in his teeth?
Miguelina: (with a confused look on her face) I don't eat them but my husband does
Toni: Oh... so you pull off the legs first?
Miguelina: Yes

Jose, Miguelina's son, walks up to us, looks at me, smiles, looks at the fan covered in bugs and says "Oh, you already pulled the heads off". Then pulls off the back segment, pops it in his mouth, squeezes out the juice, and spits out the exoskeleton. Nonchalantly followed by...]
Jose: You want one doctor?
Toni: hhmmm. Jungle protein? I thought to myself... our dads did just bring us 20 packets of dental floss...

This weeks patients

Yesterday morning Inesta arrived in labor. She knew she was carrying twins. On exam she was 5cm and we felt little toes and the body in the cervix, so we moved her to the operating room and two healthy boys were born by cesarean section, the first weighing 2.600 kilograms and 2.010. These are the youngest of 8 kids and her second set of twins. Here at CSSC, the family member (usually husband) washes all the laundry, including all the drapes and towels from the operating room and the bed sheets. The husband also goes to the land behind the hospital to bury the placenta.

This morning Nanci and her husband Wilder arrived from a town over an hour down river. Their other 5 kids were delivered at home, but after her water broke and the baby's arm prolapsed, and Wilder knew that without help, the baby wouldn't survive. She arrived and Carmen our midwife brought the doppler to check for heart tones. She wasn't able to find heart tones, but we were reassured when the baby gripped her hand and didn't want to let go. Finally heart tones were found, and shortly thereafter the little boy was born by emergency cesarean section, with a strong cry and moving both arms.

Over the last week, we have also had two precipitous natural deliveries, two snake bites, a patient with dengue hemorrhagic fever, premie with severe malnutrition and congenital abnormalities, a 6 year old with with whole body swelling and glomerulonefritis, a 75 year old man with severe anemia and dehydration, 2 women with kidney infections, kids with pneumonia, a man with pyomyositis his gluteus that drained a pop can full of pus when we opened it, a woman with a miscarriage, another who was struck by stingray barb, etc etc.

One 10 year old girl got bit by a moth called a chicharra machacuy. Although scientific sources (wiki) tell me that it's not poisonous, she arrived with frequent strong muscle spasms of her whole body, extreme generalized muscle weakness (she couldn't even stand by herself), and hyperreflexia that could not be otherwise explained. With IV fluid, one dose of diazepam, and time she recovered. 30 hours after the bite, her only residual symptom was paresthesia (numbness) in her leg that was bitten, but has complete recovery of strength and reflexes.

Brian has taken on a lot of the administrative work, and I have been coordinating volunteers and donations. After our trip back home we have a renewed energy to work and learn. Seeing family and friends was great, and although we stay very busy here, we frequently think about and pray for everyone back home. 

Back in the Saddle

After a brief trip home for my pediatric boards and to visit friends and family I am back on call. We arrived in Santa Clotilde yesterday after a few days in Lima for meetings and to start the process of getting our permanent Peruvian medical license. Being home was nice, we had a great time seeing friends and family and I ate to the tune of putting back on 11 pounds. I have a renewed energy to work after being able to reflect on our work here in Peru. I have been told and probably rightfully so to not post too many graphic medical pictures, so i will continue to post them, but try to give a warning and post them at the bottom of the articles :)
Don't worry tonight's blog will have no gross pictures, one good one I wished i would have taken today was of the face/skin of the patient listed on Toni's last "guess this rash" blog, he came in today with no rash only some scarred areas that are only a little lighter...kinda like Michael Jackson. Today was busy and we had two very sick patients one who suffered a snake bite in the hand yesterday and came in today bleeding from the mouth and had swelling up to his shoulder. He had a little reaction to the anti-venom and has a purpuric vesicle (purple blister) at the bite site, but now is sleeping with arm elevated, no longer bleeding and swelling improving. My other critically sick patient is a 5 week baby boy with congenital anomalies, born premature and not feeding well. His weight was 1.8kg, now is 1.4kg today. I am not sure if he has long to live, but is responsive getting antibiotics, feeding on newborn formula and mom's breast. Mom and dad's first baby so this is very difficult. I have never seen a sicker kid that I was not expecting to see, in the ICU, ER and with premature babies we expect to see sick kids or at least are not shocked, but when this kid arrived from up river today after a 5 hour boat trip in one of our emergency boats, I was floored. I could show pictures, but they are too sad and too graphic example of malnutrition (see previous comment) to put up. He needs any luck he can get; if he is like some of the other patients from Angoteros he should fair well.  The health technico that brought this little guy gave me an update on the kids that Centro de Salud previously cared for. Yadiera had a congenital heart defect repaired and is growing and doing great per report, and Martha Luz who was born via arm first then was stuck and somehow survived the trip down river and a crash c-section and meconium aspiration is also alive and growing. I was a little afraid to hear the answer when I asked if Martha Luz was doing okay and pleased to hear the report. Okay the power is gonna cut out soon, like it did on me last night during the 4th quarter of the Bears game (yes i did see the game on our DirecTV in the jungle.) I feel like i should get it for free with my plug for it online.  Goodnight and Happy B-day to my sister one day early!

12 Nov 2012

Happy Doctors Day!

Ernesto RN and Doctor Juan give Centro de Salud Santa Clotilde two thumbs up!

Yadira and other staff thanked the doctors with a theatrical performance

Dance troop numero uno

Victor Hugo had a baby!? cat!? Nothing like laughter to celebrate Doctors Day!

Guess the Rash

Guess the Rash. This boy is 12 years old with no past medical or significant family history. His rash has been getting worse since it first appeared two weeks ago. He also has some ear pain and on ear exam his canal is full of white material. As you could see, the rash is on his head/face and extends to his upper trunk. He is afebrile and non-toxic. It is unlikely this rash would be seen in North America.

Vaccine campaign

Our vacccine boat and home for 11 days
Dry river bed as we walk an hour to the community of Puccabaranca
In mid September I went on a campaƱa or vaccine campaign in the middle Napo River we went to 16 communities in 11 days and I saw over 300 people. We vaccinated around 250 kids and attended around 100 OB visits.  I was able to learn a little bit more about the people and their situation/life on the river. First thing that I learned is that life is tough! They work hard to produce the little food they have, often working on their chakras or farms, which are actually about 30-60 minute walk from their houses. These walks are in the mid day sweltering heat and often away from running water. They then use their machete hunched over to cultivate and clear land, then carry their food for an hour to arrive home. It became very clear to me why over half of my patients came in with headache, dizziness and back pain. Often they eat only twice a day and only drink 3-4 glass of liquids a day.
I also learned that the level of the river makes a HUGE difference in their lives. When the river is high, usually from Nov-Dec until May you can take the big boats, commercial rapidos and lanchas right up to the ports in almost every town. However, when the river is low it creates a dessert like setting in the riverbed as the water level goes down about 30-40 feet, and you may have to walk over an hour to reach the main river (see photo). I also learned that nature has changed the course of the river naturally. Our driver, Hernan who is in his 60s remembers when areas of the river ran a completely different course often passing between certain communities and was used on prior trade routes. Now all that runs in these areas is a small creek as the ebb and flow of the river during the rainy and dry season have changed the Napo’s course. I cannot explain in words nor photos the impressive changes in the river depths between the two seasons. I have included a picture as an example where you can see one community in the distance and us walking to provide care. We are walking on an area that will be about 30 feet below the surface of the river come January. This particular community is “close to Santa Clotilde” compared to several other communities.    
Close is a relative term as I want to give an example of their life; let’s say you have a 4 month child who has a cough and fever. To get to Santa Clotilde you need to walk an hour in the heat to a canoe on the river (if you own one) then if you have a small outboard motor called a peque you can drive up to Santa Clotilde for about 5-6 hours to get care. This will cost about 2 galloons of gas, which is around 20 soles ($8.00), most people do not have 8 dollars. If you have no motor you are rowing, likely with your 4 month baby in your lap against the current of the river for a full day. When you arrive in Santa you have to pay 3 soles for a consult and the doc might just say it is a common cold, here is some Tylenol. This occurs on a daily basis when patients arrive. They are happy to have the opportunity to have access to healthcare, but at the same time often wait until children or family are gravely ill due to the efforts to reach Santa Clotilde. Think of this next time you wonder if there is access to healthcare for all in the U.S. Also is access to healthcare a right????? I think it is an innate human right to have access to care and treatment, not just for those with money or insurance.

Brian Medernach
09 October 2012

Fresh Fish

Local fisherman bring us lunch!

RJ sells bracelets

One of our patients with paraplegia and a chronic ulcer has been in the hospital for over a year. He makes beautiful bracelets to try to generate a bit of income to buy daily necessities like soap and toothpaste. His mom is also creative and makes very nice comfortable hammocks out of plastic bags!

Another Classic Ulcer

Cutaneous Leishmaniasis
Can you find the amastagote?

Restful Rhythmic Rain

Mmmmmmmm. After the hot hot sun blazed for days, if finally rained all night and day, and is still cool and overcast. I LOVE cool relaxed rainy sundays! I picked a few new books from Liz's library (canadian who has lived here for 20 years) and I'm about to read Around the World in 80 Days, a classic that I never read. Then tonight we're projecting a movie, popping popcorn, and breaking open a box of vine and a bottle of cocona (local fruit) wine with some of the staff and visitors. Brian has been on a vaccine campaign for 9 days, and finally returns tomorrow! I'm really looking forward to him getting home! Life is fuller when he is here :)

Masato + naive stomach =

Victor Hugo sharing Masato with Carolyn (boiled, chewed, spit out, fermented yucca, shared by family, neighbors, friends, and strangers that sustains workers in the fields and families in their stilted houses. It's a food staple and ancestral tradition of communion).

Carolyn is a 4th year medical student from Loyola who is rotating with us for the month. She has done an amazing job on both inpatient, outpatient, and making fudge and pancakes!
Judith, one of our many fantastic nurse technicians and good friend, starting an IV on Carolyn the next day. Apparently Masato along with many other factors including a new diet, the extreme heat, and endemic parasites are a lot to handle all at once. Thanks to Judith, 0.9% Normal saline, and a fan, we saw a dramatic recovery within hours and Carolyn was back to work the very next morning!

Thanks to Carolyn for her hard work all month!

September babies



             ! FELIZ PRIMAVERA                           
                HAPPY SPRING !

Chronic Wound Healing

 He fell off a bridge at 25 years old and cannot move his legs. He's had this ulcer for over a year that won't heal. There is hypertrophic granulation tissue at the orifice and a strip of undermining over the sacrum that extends about 10cm, that won't close. In the past we have removed the hypertrophic tissue and were more aggressive with debridements, but that did not seem to make any difference. We can't do cultures but he was empirically treated for osteomyelitis for 6 weeks with clinda without improvement.
 Any ideas?

Nutrition Classes

Yoli initiates a series of nutrition classes for local pregnant women and mothers. The benches were full of people of all ages who listened attentively about food choices, textures, and portions for children of different ages, as well as pregnant and lactating mothers. A mix of local foods were displayed. Future classes will include parents and children bringing local crops, age appropriate meal planning, and learning recipes and tips from each other. With the endemic problem of malnutrition, we are starting with this small step to help insure kids are given a fair chance at growth and development.

Patient list

Patient diagnosis list:

Femur Fracture, shoulder subluxation, back contusion. Put in traction 18 yrs
Greenstick fracture-reduced and casted today
Hip fracture for the third time in the same place, elderly lady already has a pin
Hematogenous Osteomyolitis with pneumonia and big liver in 11 yr old
Tumor on rib cage with empyema in lung and very loud heart murmur
Broken nose, his wife hit him
Nephrotic Syndrome- 2 yrs old on steroids.
Glomerulonephritis- pray it's post-strep. he only urinated 10ml today
Tuberculosis- sputum finally negative
Tuberculosis- sputum still positive
Bacterial Diarrhea
Head laceration-stitched up
Miscarriage with severe hemorrhage, D&C and blood transfusion (9 hr boat ride to get here)
Ulcer on hip after stroke
Pressure ulcer for almost 2 years... it won't heal.
Schizophrenia- seeing ghosts at night and voices

8 yr old chronic cough

Today was a good day. Padre Jack is back... until tomorrow. This morning we rounded in the hospital and discussed in detail some of the complicated patients, including Shermuly who is 8 years old and has a chronic cough. She was treated for TB for 6 months last year even though her PPD and sputum AFB were negative. Her CT scan is below. She improved a little bit with the treatment but then had a recurrence of her chronic cough. She came in a few days ago with fever, retractions and pneumonia that responded to Penicillin. She has persistent diffuse crackles and clubbing of her nails. We're sending her to Iquitos for further studies. If anyone (especially radiologists/pulmonologists) have any ideas, please comment below and let us know!!

Then I admitted a guy with tropical pyomyositis, a pocket of pus that forms in the muscle. He's had fevers and leg pain for 20 days. We numbed his thigh and stabbed it with a scalpel... about 7 cm deep, and encountered the pocket of pus. We put a drain in and I imagine he'll be better within a few days.

Then at 1pm we had an administrative meeting to discuss the future of CSSC and some other pressing issues. For example, we have emergency boats up and down the river to transport patients here and to Iquitos. Many of the motors are broken so when emergencies come up, we're stuck waiting until the motor is fixed... Our motor that was supposedly fixed today in Iquitos and on it's way up broke down again.. so we have no boat to transport the 3 patients who were ready to go to Iquitos tomorrow. We discussed helping communities build chicken coops, fish ponds, collecting debts that are owed to us, charging patients on a sliding scale rather than flat fee for care, and more.

At 7pm we had a conference call with Canada, Chicago, and Lima to try to coordinate some PANGO projects for this and next year. Brian and I are starting a Non-for-profit in the US and we hope that through this, we could secure some funds of the many new and ongoing projects we have here.

There is really never a dull moment here. The town electric goes out in 45 minutes, so I will head home from my office and do a few dished (to avoid an ant invasion) before I go to bed.