Thoughts from an Alumni – Judith E Tintinalli MD MS
It was the beginning of the rainy, high-water season. The village, in the Amazonian flood plain, was enveloped in an ankle-deep slurry of water, silt, mud, and garbage. We were told this was just the beginning, and by its peak, the water would rise at least another 3 meters.
Our first visit was to the 200-person stilt village of Libertad. We trudged from boat to the clinic wearing knee-high rubber boots. Although surrounded by rivers, most villages have no water source, and all drinking water must be brought in. A family bathroom is typically a corner draped with a piece of tarp or muslin to give privacy when using open holes in the house flooring for relief—which of course empties into the aforementioned ankle-deep slurry in the village.
Just as clinic was about to open, one of our local team tapped me gently on the shoulder. ‘The family would like you to see their grandmother—she is too sick to come to clinic – can you see her? ‘Sure’, I gamely said. ‘Which house?’ They pointed me to a 10-foot board set up across a void to connect the ‘clinic’ to another family home. I quick-stepped along the board, entering the family home—bare of furniture except for a small table with 1 pot and a few small chairs. A 70 pound, very old woman (96, according to the family) was lying on her side on a cotton blanket. The family told me it had been a month since she was able to sit up or stand. ‘She doesn’t like being touched’ they said. I knelt on the floor at her side and spoke to her in Spanish in soothing tones. ‘She’s pretty deaf’ they said. But she heard something. I held hands with her, and she turned towards me. Strong grip. Moved both arms and legs. Starting my exam head to toe, she was blind in her left eye but no jaundice. Chest and heart, clear as a bell. Abdomen, soft but with hepatomegaly and pain in her RUQ. Checking her skin, wow, I thought. No decubiti, her body clean as a whistle. The family said they bathe her twice a day. We had a SonoSite, and our patient allowed a cursory FAST-type check- nothing amiss we could find. I stood up. ‘Thank you for letting us examine your grandmother’. What do you think is wrong with her?’ I said. ‘Old Age’ they said. I nodded respectfully. ‘You are right,’ I said, ‘And you have taken good care of her. She is lucky to have such a wonderful family’.
I’d been attracted to the idea of the Amazon ever since I saw the movie ‘El Abrazo de la Serpiente’ – and on my personal yardstick of life, things coalesced so I was able to join AmazonPromise in February 2017, on a medical trip into the Peruvian jungle.
Amazon Promise is a small but complex 28 year old NGO headquartered in Massachusetts and Iquitos, Perú. It operates a clinic in the Iquitos stilted city of Belén, Perú, and visits a series of remote Amazonian villages about four times a year to provide the basics of medical care. Jungle clinics are based out of the Yacumama Lodge, on the banks of the Yarapa River, a full day trip from Iquitos, as well as base camps set up in communities they work in. Amazon Promise also employs 30 or 40 locals and indigenous to translate, transport, and maintain the medical trips, staff local medical clinics in Iquitos, develop water reclamation systems, teach preventive care concepts and simple wound management, and perform cervical cancer and HIV screening exams. The Amazonian area is pretty much ignored by the Peruvian government and its health system. Mid-level services are only available in Iquitos, which at best requires a day or more of travel in an open Amazonian dug-out canoe. Making matters more difficult, what health care there is in Iquitos, especially specialist care like ophthalmology, is pay-as-you go.
Adventures start in Iquitos, a super-funky, energetic, fairly dilapidated port city on the banks of the Amazon. It is the only port in the world that can be reached only by river or by air, not by road. The city was founded in the 1850’s as the major trading hub for the Peruvian rubber plantations, and when the rubber boom collapsed, it morphed into a city for drugs, shamans and ayahuasca *. Now it is banking on eco-tourism. The 60s are alive here, with long-haired, guitar playing, tattooed men and women in ages ranging from late teens to the 7th and 8th decades, hanging around the Malecón and Plaza de Armas. One of the best experiences in the city is bulleting around in frenetic 3-wheeled ‘motorkars’. Each trip within the city costs about 75 cents and every trip is more fun than a Disneyland ride.
At the Clinic
Our clinic days began with a magical ride through the morning mist of the Yarapa River, to the confluence of the Ucayali, to the village banks. The ‘clinic’ could be a schoolroom, a bare village community house, or a family’s living room. The ‘offices’ are low tables with several small chairs, and each table has a small set of boxes holding the most commonly used meds (like Tylenol and abendazole), and lots of Purell. Potable water is provided in 55-gallon tanks brought with us in our Amazonian dugouts.
Man, it was HOT! No fan, no cross-ventilation breezes. Sweat started on the chest and back, and then around your neck, ears, and scalp. Eventually sweat dripped down your forehead and fogged your glasses as it stung your eyes. Note to self: next time, bring a sweatband!
We had a dentist, a humanitarian Peruvian GP from Iquitos, and a laboratory. But here’s what labs we could get: malaria smear, acid-fast for TB; POC glucose and Hgb; u/a; pregnancy test; HIV screen and other STI’s. That’s it. No internet. No phone. We were all flustered by the lack of contact with EPIC to do our drug dosages, no apps, and no web-based resources to answer our questions. The AP pharmacy table had several formularies. Another note to self: next time, bring favorite medical handbooks. Our meds were purchased at the local ministry of health pharmacy, or repurposed/donated from relief organizations.
The caseload was mostly ambulatory type. Many children. Several cholesteatoma. Lots of vision problems, mostly cataracts and pterygia. Despite the blazing sun, no one could afford sunglasses. One woman with glaucoma couldn’t afford her eye drops, nor could she get to Iquitos even if she had the funds to buy her meds. All I could do is palpate the ocular globes. I remember being taught that a normal globe should feel like a firm but ripe tomato. Any harder, think acute glaucoma. Pressure seemed fine. A baby with scarlet fever. I hadn’t seen that since med school, and none of the other faculty, students, or residents had ever seen it. (Age has its advantages.) Children with rashes after swimming in the river. What could the rashes be? One rash I thought was bullous impetigo. A pregnant woman with new onset migraine. A 7-year-old boy with fever but no exam findings— UTI! Lots of complaints of dizziness. Even in the older population, this always turned out to be dehydration, identified through symptoms or BP check. Only one child complained of dizziness. This 11-year-old boy worked in the farm all day, starting in early morning until about 1 pm, but had no water to drink. We supplied his mother with WHO rehydrating solution packets and gave the family a few bottles of water. A mother brought in her newborn 30-day old boy with vague chief complaints: Sleepiness, occasional cough. We breathed a sigh of relief at the 30-day age, but the infant looked rather scrawny, and he looked listless even while sleeping. Fever? No. Eating well? Yes, said the mother. No other disturbing symptoms. We had the mom wake up the infant and breast-feed. No retractions, no grunting. Improved responsiveness. What to do? Our only tools for diagnosis were our clinical skills. I decided to give the neonate Ceftriaxone. We gave it IM, and that resulted in healthy cries and better energy. More antibiotics? No, that was a stretch as he looked better. We checked him at the end of the day, same scrawny baby. The location of the village enabled another follow-up check in 36 hours- the neonate appeared OK. We all breathed a sigh of relief. Making a decision to move an infant, and the entire family, with costs for medical care and lodging and meals, on a long boat ride to Iquitos is a big decision. We made the right decision. No further antibiotics.
One clinic day, we were called to see a 22-year-old woman with knee pain. She couldn’t walk-could we go to her home? She had knee and ankle pain and thought she must have sprained her ankle, though she couldn’t recall doing it. On exam, she had a knee effusion. We tapped the knee. Maybe 1 cc of fluid. Now what? Impossible to process for culture. Can the lab do a gram stain? Yes. Result: a few G+ cocci. The first response from residents and interns, was ‘contaminant’. No said I, we were looking for abnormality, and this is it. What are our treatment options? Not much. We opted for Ceftriaxone which could be given IM with lidocaine x 7 days ; and then po Clindamycin as long as the med held out, hopefully 4 weeks. Follow-up? Likely 6 months later.
A Peaceful Night-Or Not?
Nights at Yacumama Lodge are dark. The heavy tree canopy blocks out stars and moon. Delicious dinners of rice, chicken, cabbage, with water, beer or soda, and sautéed plantains for dessert, were followed by quiet conversation and reading by headlamp.
Then suddenly–what’s that calamitous noise?
One of our indigenous workers had come in the black night in a dugout canoe with family and grandmother. The grandmother was moaning in pain. The family carried her into the entryway and placed her on a padded weight bench (that must have been placed for just this purpose). I checked her and identified general discomfort but definite LLQ pain. No rebound. She had been evaluated at a clinic earlier in the day and someone remembered a systolic BP of 180 at that time. Repeat BP was 100/60. We started a L of normal saline. We obtained history from family as best we could. Just sudden onset of abdominal pain. I was careful to work respectfully and as a team with Dr. Luis, our Peruvian GP. He confidently ordered IV Nexium and IV Hyoscyamine for the patient. Hyoscyamine? Nexium? Hyoscyamine seemed to ring a bell, some type of anticholinergic. Dr. Luis said it was great for GI spasm. I thought she had acute diverticulitis, and conferring with Dr. Luis, I added IV Ceftriaxone to the therapeutic cocktail. We had only oral Flagyl. Wait to give any po meds he said, until her abdomen has calmed down. In less than 30 minutes, her pain had abated, LLQ pain had diminished. Sonosite was helpful to r/o leaking or ruptured AAA, but mostly it helped by calming us modern techno-dependent doctors. We were pleased to identify a GB stone, but she had no RUQ tenderness. We did not identify any free air. It would have been a major effort if we anticipated an abdominal catastrophe to try to get the patient to Iquitos by riverboat in the middle of the night, with tough currents and lots of floating trees, snakes, and caimans ready to swamp our boat in the Amazon. So—as she was improving, we gave her 1 gm po Flagyl, continued IV saline, and kept her on the weight bench for the night. Dr. Luis was very happy to check on her intermittently. Our wake-up conch sounded at 7 am. I rushed to the weight bench. There was our patient, eating an orange, hungry, no abdominal pain, ready to be canoed back home! We did have her continue 3 more days of po Cipro and Flagyl, just in case. But I re-learned that Hyoscyamine is a great drug!!
In the Embrace
I’m hooked. But why? The Amazonian rainforest is a storied area. It grasps you in its embrace. The struggle for existence continues in its villages, its rivers, its forests, its people. It is a struggle because the desire for minerals, gold, lumber, drugs and deforestation for agriculture continues despite efforts to hold it back#. Those living in the river communities have great skills – they are terrific watermen, fishermen, hunters, subsistence farmers, lovers of nature and solitude. What is their future? They have no skills for cities. The young men and women make a living as eco-tour guides. Many are fluent in several languages. City life would strangle them. So, our medical ventures may be just one small step to help maintain and maybe even improve their precious way of life. But the way of life isn’t easy. It is hard and precarious no matter what we do.
Thirty-six hours after arriving back in the US, I changed roles and became my usual self: tertiary-care ER doc. I felt disequilibrium and a bit of agitation. Something is wrong with our system. Did I function reasonably in a remote setting using my brain, hands, eyes, and ears? My medical belief system had to change in the jungle—I had to trust only myself. But once back in the US, I became irritated with the ponderous way we have decided to practice emergency medicine: CBC, BMP, CMP, ESR, CRP, CT, CXR, MRI , EPIC, etc etc. There are great benefits from technology, but are we losing the ability to think, analyze and remember without common technology tools? I want to take a breath, step back, and try to move my technology curve backwards a bit.
*a hallucinogenic drink prepared from the bark of the Banisteriopsis caapi vine and the Psychotria viridis leaf. Effects include visual and auditory stimulation and psychological introspection. It also causes vomiting and diarrhea, and may have antihelminthic properties.
#For some great reading:
Joe Kane. Running the Amazon. Vintage Books, 1989
John Hemming. Tree of Rivers – The Story of the Amazon. Thames and Hudson, 2008.
Buddy Levy. River of Darkness: Francisco Orellana’s Legendary Voyage of Death and Discovery Down the Amazon. Bantam Books, 2011
#For more information on Amazonian medical journeys: www.amazonpromise.org Malecón Tarapacá 322, Iquitos Perú. Rosa is English speaking 965-000-064