Out in the communities, we have a group discussion/lecture/learning didactic (charla) in each village we go to. On my first venture up the Tambor River, Lucio gave talks on Dengue Fever, diarrhea, and Respiratory Infections. He is such an amazing teacher! He is very organized and discusses clinically relevant points that parents, families, and health promoters can use to care for each other. We will discuss Malaria (which is on the rise), burns, first aid, hygiene, and a few other topics when we leave on our next vaccine campaign- in three days. Tomorrow's departure was postponed.

Dirty Water

We discovered that all the water here in Santa Clotilde is contaminated with bacteria/parasites that are resistant to boiling. All our patients and staff have been drinking this contaminated water. We are hoping to get a water purification system to keep the town healthy. In the meantime, we'll take our anti parasitic pills and hope that the heavy metal levels in hair/fish/water are shared with us once they are processed.
1. Bacteria- Who's been pooping in the water?
2. Parasites- roundworm ascaris, hookworm necator, whipworm trichuris, threadworm strongyloides, tapeworm hymenoleptis
3. Protozoa- giardia, entamoeba
4. Mercury- due to gold mining upriver, contaminating and harming our kids... think twice before you ask for gold for christmas, because looking pretty may not be worth the devastating environmental impact here. The difficulty is that mining brings a lot of business and jobs to our communities, and with out many would go out of business.
5. Lead- also affected by gold mining... is this why are kids have belly aches, anemia, and are not growing? or is it the parasites and malnutrition?

Headed to Alto Napo

Where the streets have no name... actually, where the towns have no streets. I'll be leaving on a vaccine campaign on Wednesday for 10 days. Eight of us will live out of a boat, bathe with river water on the boat (in a little bathroom?), eat jungle animals (although I refuse to eat monkey), wear long sleeves and pants in 80 degree weather to avoid getting eaten alive by mosquitos, and prevent hundreds of kids from getting vaccine preventible diseases. The midwife loaned me her boots to keep my feet dry and I'm heading out to town to look for a light long sleeve shirt. Most everyone upriver speaks Kichwa, an indigenous Ecuadoran language, so I'll be trying to learn a bit of that as we go. We will be passing out anti-parasite meds to everyone, since EVERYONE here has parasites. I'll also be meeting with the apo (chief) of each village we go to in order to set the groundwork for an integral community assessment project that will help us understand how to improve the health and lives of those who live in the communities we serve. I will also discuss the details of International Medical Relief's medical mission trip in July. We have a great group, and I'm excited to learn first hand how people live out in the villages.

Busy day!

The morning was moving along smoothly yesterday, when I was called from lunch to see a man with a snake bite on his hand that happened while he was cultivating his yuca. Josue the nurse technician was already starting an IV to give him antivenum. Amist evaluating him, another man walked in who accidentally cut his forearm with a machete. He has a bloody towel wrapped around it. Inside, we found the laceration to be covered with a cut chunk of human hair. This is a common home remedy here to stop bleeding until medical care is sought. As I finished sewing his arm up, a lady was brought in on a stretcher with severe headaches, fever, and weakness for 10 days. I had just enough time to get her history before I was called in for in impending delivery. When I arrived, Lucilida had been pushing for over an hour and the head was not descending, and the heart tones were dropping. After a failed vacuum attempt, we decided to do a cesarian section. Mom and baby are doing well! The man with the snake bite doesn't have too much swelling and although his bleeding and coagulation time are very prolonged, he will do just fine. The woman with fevers likely has pyelonephritis and the man with the machete wound was sent home with followup tomorrow. Overnight we had a different woman with pyelonephritis and hypotension, maybe urosepsis. She responded to 5 liters of fluid and is much better today. I was so exhausted by this afternoon that I napped from noon to 4pm. There is never a dull moment here at the Centro de Salud!

Life and death here in the jungle

Over the past month we had our first patient die in the hospital. He was an older male who came in with symptoms of shortness of breath for three nights, where he could not breath lying flat. Fr. Jack hooked him up to our EKG machine and found ST changes which means he had a heart attack. We admitted him to the hospital and gave him what he would have recieved at home, short of a cath to open up the vessel... aspirin, beta blocker, morphine, oxygen, lovenox (blood thinner), and a statin. However his heart was too damaged to recover and on his fourth night in the hospital he progressively worsened and at 2 am, the resident Laura who was on call and Fr. Jack had him connected to the EKG and were trying to recessitate him and saw his heart rate slow down and he died with his wife at his bedside.
Our second patient that died was a pleasant elderly woman named Marcela who had end stage uterine cancer. She came to clinic dehydrated with sepsis from a urine infection. We treated her with fluids and antibiotics and she improved enough to go home to be with her family. Although she did not eat while here in the hospital she did eat and drink enough at home for the next 3 weeks, however her cancer progressed and she died peacefuly with her family 2 nights ago. Her husband came to clinic yesterday morning to tell us and get the death certificate. He spoke with Fr. Jack and told him their history. The husband had married early in life and his first wife died in childbirth with their 7th child-who also died in the delivery. He later met Marcela and they had 12 children which 6 had died. He is 20 years her elder, and for the past month he did not show much emotion. Today after church Padre Jack, Sister Gigi and one nun in training and I went to the wake and gave a blessing. It was a touching scene for me to see a small community center with a cement floor and roof with the body wrapped in a simple white cloth covering her face in a simple wooden box with flowers at the head and feet. The coffin sat propped on some wooden boards that were balanced on tree stumps. It was when Padre Jack had the family members bless her body with holy water when her husband, stoic through all, began to weep and needed to be supported. Later in the day 3 students who are working here: Mark, Suzana and Laura were walking and saw the burial which they stopped and attended. They took some pictures which the family allowed and even asked for some copies to be made and given to them. During the wake the room was filled with over 10 grandkids running around, smiling, maybe oblivious to what was taking place. An interesting contrast to see such young vibrant lives contrasted against the inevitable passing we all will encounter

25 March 2012

Today’s Specials

Rabbits Sachavaca

Overall the food in Peru is pretty tasty, however the regional taste is quite different from other parts of Peru. The reason being is that they mostly live off the land and hunt animals in the jungle and eat the meat or “carne del monte.” We have eaten quite a bit of new foods which Antoinette has blogged and shown pictures of in the past. On my way back from Angoteros last week I had "tortuga" or turtle for the first time. It was in a stew with potatoes and carrots and was quite delicious and served over rice of course. Most meals have white rice as part of the course but I wanted to run through some of the stuff we have eatensince we’ve arrived.

“Pollo regional”, local chicken, the kind that is crowing and wakes you up at 5am, then you eat it for lunch, very good and way better than the steroid, antibiotic filled chicken we eat back home. “Conejo”, rabbit, our friend Lucio who is originally from the south prepped 2 deep fried rabbits as it is their traditional food, they were the tastiest treat yet; although the claws and all were cooked and it looked a little scary. Antoinette had the pleasure of eating “Mahas”, which I’d say like a large guinea pig, some people have them as pets. “Sachavaca” which is a wild pig in the jungle, very tender meat. People do eat monkey further up river and also macaws (Fr. Jack says nothing like a $5000 lunch-which is what they would sell for in the US at a pet store.) There is a variety of fruits and veggies. They have yucca, one of their staple foods, which is a large root veggie similar in appearance and taste to a potato. Carrots, onions, pepino (cucumber), aji (pepper) both picante y dulce (hot and sweet). There is an avocado tree outside our meeting room, but still not quite ripe. Outside of our house is a guava tree and papaya. Overall a neat, new and delicious selection of food, the main thing lacking is green veggies like lettuce, spinach, broccoli, etc because it is too hot and humid, and they get moldy.


24 March 2012

Guess the rash?

First birth "en cuclillas"

In the corner of our new birthing room, Edith en cuclillas (on her knees) and her husband supporting her from behind, delivered her seventh child, endearingly named Mick Brian. Most women on the Napo deliver at home, like Edith had done with her first 6 children. She was only 36 weeks pregnant and had been contracting for over 24 hours when I met her. She mentioned how nervous she was because with her other children, she had pains for only 30 minutes before they delivered. Something was different. I brought her back to the hospital with me for an ultrasound and to monitor the baby. Her birth plan mentioned that she wanted to deliver her baby while kneeling, and I although we had not done so before, I wanted to accommodate her wishes. We put some blankets on the floor, and although the labor room was very bright, large, and full of people (unlike her small, dark, wood one room house), she had a good birth experience. How could we improve on this and make births here more enticing and culturally comfortable for high-risk women? Edith, Mick Brian, and "big" sister Kimberly.

Momma decided that 6 kids are enough (one miscarriage and one died of pneumonia) and begged for a tubal ligation. Luckily Drs. Katherine Kaplan and Joe Welter, OB/Gyne's, were here and we did her tubal together. She was discharged two days later with a big smile on her face, husband and Kimberly at her side, and baby in arms. I love happy endings :)

Rio Tambor Vaccine Campaign

Vaccine campaign to Rio Tambor for three days

We pull up to Santa Elena to be greeted by a dozen kids with protruding bellies, thin dry hair, and limbs as skinny as sticks. It's status quo to puke up or poop out ascaris (roundworms between 2-6 inches long usually). Why so much malnutrition? Access to food? Access to clean water and parasites from river water? Parents drink too much masato to give the kids the attention they need? Domestic Violence? Furthest from Santa Clotilde and lack of access to medicine/resources?

Nuevo Libertad
Where can we pee? - behind that tree over there.
What about #2? -behind that tree a little further over there. God's toilet-the tree stump- works just fine so long as the microbugs on the grass don't jump too high. The kiddos here were gorditos, healthy and happy and hanging off mammas boobs. Why just a short distance away, with what I imagine to be similar land and resources, do we have a whole population of healthy kids? Is it the community leadership, the wise local health promoter, less masato or domestic violence? More agriculture and animal husbandry? Better birth control methods? Lucio gave a charla on Dengue "Bone Break" fever

Allison and Laura the Canadian residents, Fernando the technico de enfermeria, Elmer the technico student, Hernan the mechanic, Elsa the cook, and myself got ready for bed. We found the biggest house in town and invited ourselves to stay there. We set up our sheets and small mattress under our mosquito nets. As everyone slurped down their chicken soup (which I'm allergic to), I picked apart 5 tiny fish, deep fried with whited out eyes looking back at me. They were delicious, and I've eaten enough fish here to know how to remove the meat to avoid disrupting and swallowing the bones. Dinner was served with delicious hot chocolate, just a few degrees warmer than the jungle air.

In Vista Hermosa we continued to hunt down kids who were behind on their vaccines. We found the baby we were looking for! "What is her name?" we asked the mother of this chubby 2 month old baby. She looked at us and shrugged. I don't know, what is your name she said, gazing our the two Canadian residents. Allison and Laura told her their names, and she confidently pronounced "Her name is Allison Laura." What an honor! Allison later became the namesake to a boy patient she had delivered too! Our next day and night were was spent in San Pedro. We pulled over on the side of the river and prepared to eat a meal that Elsa our cook had prepared for us. "It's Majas," she said. It smelled delicious... until Elsa handed me a plate with a hand on it. I wasn't sure what to do with it, and she encouraged me to pass it to those ready to eat outside the boat. I didn't want to pass it to Allison, fearful that she would be as disgusted as I was. As you see below, she wasn't able to eat beyond the elbow. "It was like eating my brother" with the hand so real and alive. Unfortunately after seeing the hands and head of this majas, even the smell of the meat turns my stomach.

Adventures with Judith and Lucio

“Be at the port at 8am” he said. “We’re going to pick camu camu.” We had no idea the adventure that awaited us. We embarked on a wooden pecke pecke with Judith, her brother Alberto, her boyfriend Lucio, and Fabio. Lucio loves to teach us all about the native plants and animals, and if he were any plant, it would be camu camu. This non-citrus fruit has the size and flavor of a key lime, with the tough skin of a plum. It's very sour and acidic, and has 10 times the amount of Vitamin C as an orange! Brian, Lucia, and Fabio were swinging from the bushes growing in the water like monkies to reach the ripe maroon berries. As the boys gathered the fruit, Judith and I rinsed it in the river water, pureed it with a pestle, squeezed it through hospital gauze to strain out the seeds and skin, and mixed it with sugar and water to make the best juice ever!

Brian pulled out his Nimbus 2000 fishing pole, and our compadres pulled out their fishing line tied to a scrap of wood, and they were off. Brian fell behind in the first 5 minutes when his long cast caused the lure to lodge itself below a sunk branch. "Sacrifice the lure and keep going" he said to himself. We caught small catfish that were quickly thrown aside on the bottom of the boat to be used as bait... I learned later that dinner in the villages sometimes consists of 5 of those little fish, and they are very tasty. Luckily Lucio had the insight to bring some bigger fish (that I learned how to scale and gut) to fry up to feed the six of us, along with a pot of chicken soup.

We saw a lush toronja (grapefruit) tree growing up a hill from the riverbank and stopped to talk to the family and buy some toronjas from them. We climbed up the hill to find their house- a wooden platform on stilts with a palm leaf roof and some long branches tied up to make an open fence along the perimeter of the platform. They had some fishing nets and clothes hanging on lines in the house and backpacks hung on nails. Below the house many pigs and chickens, and a few water buffalo were wandering around lazily. Mister Buffalo was very intrigued by Judith's pink floral umbrella left on the green grass, and having never seen a pink floral umbrella before and misinterpreting it as a patch of actual flowers, he moseyed over and geared up to take a bit, but not fast enough for us to rush him and save our one hope of shade for our 2 hour boat ride home. Not only did Alberto and Fabio pick toronjas, but they grabbed a few sidras. Sidra is a citrus fruit that tries very hard to be as sweet as an orange, but with grapefruit ancestry,
it doesn't quite cut it.

The yacht.. Dad's dream come true

Baby hummingbirds

I thought of Mamacita Medernach
when I discovered this
hummingbird nest!

Swallow a coin

It’s 7:15 am on Wednesday. I’m on a rapido headed to Iquitos to transport Leopoldo, an 23 month old who swallowed a coin 3 days ago. We sedated him and looked down his throat with a laryngoscope only to discover that the sol had passed into his esophagus. When he awoke, he was active and eating so we sent him home, knowing that most coins will pass without complication. Last night, he returned to the hospital with his grandmother. He had been vomiting and choking for 3 days, and had not been able to keep down food all day. We are worried that he sol (which is slightly bigger than a silver dollar) is still in his esophagus and will need to be removed endoscopically. Being that this is an emergency, I am traveling with them to Iquitos. We will arrive at the port in Mazan in 5 hours, then take a mototaxi for 15 minutes to a port on the opposite side of Mazan, where we will get on another boat for 45 minutes to reach the Mercado de Productos in Iquitos. There, either our nurse or an ambulance will be waiting for little Leopoldo. This morning he looked much more content and was eating crackers and drinking coke... and then the vomiting started again.


Angoteros y Carnival

I am writing my first blog in a while and I have much to talk about so I think I will divide it into 2 or 3 entries. I am typing this from the back of the hospital boat as I head up river for the next 5 days. I will be working in a small native community called Angoteros. They have a small clinic or Posta de Salud. I am going to relieve our other Peruvian doc, Juan Jon who has been up there for 3 weeks. He is going to head further north to the border with Ecuador and work a few days at the Centro de Salud de Pantoja. On his way back down the boat will pick me up and we’ll all head back to Santa Clotilde. I am both excited and nervous. I will be there pretty much alone. There is a technico de salud , a laboratoristo (lab tech) and a midwife in Angoteros as well, but I think the technico will be heading to Pantoja for their short trip. So that leaves me, myself and I as the health care worker. Thank God there is a midwife because I still don’t have even close to adequate skills as an Ob/Gyn, but I am reluctantly learning more each week. My Spanish is getting better, but it won’t help me much in Angoteros as this is a native community and most speak Kichwa. I would love to take pictures and send them, but I broke our camera about 3 weeks ago.

I went to the Arumisha (a-room-eee-shaw) to celebrate Carnavale. The arumisha is a palm tree that is decorated with ornaments and all day long people dance around the tree and sing and throw water on each other and smear dirt or colored dye on each other …..oh and they drink. I went and as I arrived so did the rain, but that did not stop the party it just added to the fun. We passed around the beer, sang and danced. I had the camara in my pocket, and I thought I was clever enough by putting it in a plastic bag before I left home. However, I was not smart enough to ensure it was completely sealed and it got ruined. I don’t know why I was initially surprised that it got wet, we are living in the middle of the rain forest.

Although Carnevale is widely celebrated in town with each neighborhood having an arumisha over the course of several weeks in February, I was quite surprised to find that this community is not as religious as I had expected. In talking with Lucio, our one officially registered nurse who is from the south near Cusco, he said the people in the north and here on the Napo River and not very religious (Catholic or otherwise) like in other parts of Peru. They do live off the land, but I was expecting more respect for the land like we see in our Native American culture, maybe I’ll see more when I go to the communities. However although the church is not overflowing on Sundays the services are nice and Fr. Jack is not only a great doctor he gives fantastic sermons that are relative to the conditions and ongoing struggles on the river and in daily life as it relates to the readings. The church is an impressive work of architecture in my mind. It was built I believe in the 1950s when a group of volunteers came from a Canadian farm community (as there was a group of Canadian nuns working in Santa Clotilde) and the town needed a church, so what did they build? A barn of course! The arches for the ceiling probably go up 50-60 feet and it was solidly built as it still looks great today. We have been on the boat 3 hours now, I am gonna enjoy the view, only 2 more hours to go before we hit Angoteros.