On the boat to Iquitos

I'm sitting on the back our our hospital speed boat, heading to Iquitos, with the bright sun reflecting off of the calm water to my left. To my right, the sky is somewhat overcast and Treycy is sitting in her mom's lap, smiling with a cast on her arm. Grodier, an amazing young carpenter and father of three, is laying on a stretcher in the front of the boat. He can't walk and we suspect that he fractured his back after falling down carrying a door. Our new pharmacist Luis Alberto is at my side. Since his arrival, patients have not wanted for any medicines. He does a good job.

Charlie is home with dad, and for the first time I'm traveling without him. Knowing that we should return by tomorrow afternoon to Santa Clotilde makes this a gentle transition. I have no worries... I came home from my first "real" call two days ago (in other words I was in the hospital the whole evening, overnight, and then all morning rounding on our 25 patients and tending to patients who arrived with malaria, vomiting, and dehydration). Brian was in the shower. Charlie was fed, bathed, clothed, and watching Rio2. The laundry was done, the house was clean, veggies washed, powdered milk made, and he had food waiting for me. So as you could imagine, I'm loving this boat ride... it's the first 

time in over a year I've had to myself. 

What a miracle it is really, to be here in Peru.
Charlie is 16 months and I've been considering weaning him from nursing. The local wisdom that I consistently hear while talking to other mothers here is "put toothpaste on and then he wont want to nurse anymore." After weeks of contemplation, I tried it. It worked like magic! After one taste of toothpaste, he wanted nothing to do with me. I offered him a bottle which he happily accepted. Multiple times throughout the day he would re-address the issue, pulling my shirt down and digging for a drink. Every time, he saw the flaking toothpaste and the smell of mint, looked at me and cringed his nose, and walked away. After 15 hours, I actually gave up. He was half asleep at 10pm, fussing and crying, and I was tired and overfull, so I gave in. I thought maybe a bit of a slower transition over a couple weeks would work better for me.

Work has been busy and fulfilling. I feel so happy to be able to meet the needs of local

families. Last night we gave Treycy ketamine to reduce her fracture and cast her arm. We played lullabies and talked about rainbows and butterflies and she smiled. This morning I walked over, knocked on her cast, and asked her "when did you put this on?" and she giggled, shrugged her shoulders, and replied "I dont know." The beauty of ketamine is that kids don't hurt and remember nothing. We also have 3 kids in the hospital with glomerulonephritis and high blood pressure, three patients with HIV- two of whom are incredibly sick, a bunch of people with pneumonia and possibly TB, a few kids with severe malnutrition, fevers, and big livers. One 14 year old boy had surgery for spina bifida as a baby and although he can walk, he has ulcers on his butt and foot because he lost some of his sense of feeling and forgets to shift his weight. He's healing well. We had a woman who was 22 weeks pregnant with a severe infection in her belly who ended up delivering a very premature baby. Another woman was on her way to our hospital from 4 hours upriver and ended up delivering TWINS en route, in her canoe. The mom and full-term healthy twin girls arrived healthy and breastfeeding and went home two days later. 

In Iquitos, after bringing the patients to the hospital and ensuring they get the X-rays and care they need, I'll be shopping to re-stock our pantry and buy a few fresh items for thanksgiving dinner. Although Santa Clotilde is a small town, we find almost everything we need there. For the things we cant buy in Santa Clotilde, we go to Iquitos. For the things we cant find in Iquitos, like good ground coffee, hershey bars, and peanut M&Ms to fulfill Brian's addiction, we phone a friend and the monthly volunteers are often able to find room in their bag for us. We're so grateful for all the support from back home that allows us to serve here!

Felicidades Vanessa, Bill y Baby Mia Valentina!

Vanessa is one of our superstar nurses. Having surpassed a couple of pre-term labor scares, and enjoying a fun filled baby shower last night at Lili's house (below), she arrived to Centro de Salud Santa Clotilde this morning in labor pain! As you can see above, she's ready for this baby to come!

                

                    Can mom or dad feed a baby faster?

Padre Jack, making balloon animals!! What can't he do!

One last ultrasound for Vanessa! Baby looks good!

After saying an "Our Father", as is custom here, doctors Yesica and Toni perform a Cesarean Section, to find, as suspected....

A perfectly healthy, gordita baby girl Mia Valentina!! 

God Bless Vanessa and Bill and Baby Mia!

X-Ray

We've recently have two young mothers admitted with active tuberculosis. One lives here in town, and active TB was detected two days after she gave birth to her 5th child. Another woman from upriver came in to clinic with her 4 month old (her 4th child) and was diagnosed with active tuberculosis. All 9 children are PPD positive and need chest X-rays, as do the husbands and other family members. We need to know if these kids have active tuberculosis (which in children is sometimes asymptomatic), and the only way to know is based on chest X-rays. If we give them prophylaxis against tuberculosis and they have active tuberculosis, the bacteria will become resistant and transform the infection into a very hard to treat dilemma.

Do you know the diagnosis?

We do not have an X-ray machine here at Centro de Salud Santa Clotilde (CSSC). This is #1 on our needs list at the current time. We serve over 30,000 people along 250 miles of river. Our top three most common diagnosis here at CSSC are 1) infectious disease/parasites/abdominal pain, 2) respiratory infections like pneumonia, and 3) musculoskeletal complaints like fractures and trauma... most of which "require" an x-ray. It costs $100 per patient to go to Iquitos (on the fast public boat) for an Xray, most of which we end up covering because most of our population are subsistence farmers and don't have that amount of money.

Some families choose the "wait and see" approach to fractures in their children due to fear of the cost, and children end up with permanent disabilities. Without X-ray, we treat complex pneumonias including tuberculosis and attempt to put bone fractures back into place. We had a premature baby born with respiratory distress and after 10 days of no improvement she went to Iquitos and with a simple X-ray was diagnosed with a diaphragmatic hernia (intestines herniated into her lungs). Stranger things happen... we recently had a woman who swallowed a fish bone, but on evaluation we saw nothing in her throat. She admitted that it was no longer in her throat. On her second day here in the hospital, she was alert and talking, and we felt the fish bone starting to poke through the skin of her neck, and hours later she died. Maybe the X-ray would have detected the fish bone earlier and saved here life.

We have a long list of people who need X-rays, and we have rampant tuberculosis in the area, and we have a 35 bed hospital, and we have a fantastic radiologist at U of Michigan who reads all our X-rays (done in IQT)  for us, and we recently had a volunteer pulmonologist Dr. Wayne Farmer who gave two amazing talks on reading X-rays and tuberculosis, and we are living in the 21st Century. So why don't we have an X-ray machine? I ask myself this question almost daily. We are actually just $150,000 away from a portable digital X-ray machine, and have high hopes that the local government here will come thorough with funding next year, in collaboration with the local rotary club and maybe other generous donors. This will allow us to bring the X-ray machine to our 100 communities and formalize a tuberculosis program.

Cutaneous flour migrans

This is a bag of flour that we use to make pizza, pancakes, roux, tortillas, etc. 

"Cutaneous flour migrans"

 Most of the bugs come out with sifting, and we could use a little extra protein anyway!

Young couple, new parents

Congratulations to this young couple! Their beautiful baby boy was born quickly, with Brian present in case resuscitation was needed for the presence of meconium. Otherwise the midwife does the delivery with the nurse present for the resuscitation, and we're only called for complications. A great majority of patients here on the river deliver at home, but despite this, our midwives keep busy!

Just a typical Monday

     Interesting how when one becomes accustomed to their daily routine how some unsual things seem to be ordinary and simple. 

     I will describe the day of work I was reflecting upon. It was a Monday morning a national holiday and a day off of work for all the staff that did not have a call in the hospital, myself included. I woke up to a cell phone call at 6am from our nurse who was in Iquitos for the long weekend. She was able to receive a message (as our fixed telephone lines were down) from an outpost about an 8 year old boy who was with a fever and very sick. So my day off turned into a beautiful day trip on the river. I called one of our boat drivers; a nurse technico in the hospital as well. By 730am we had our supplies, IV medicines and fluids, stethoscope, etc and off we went. After 4 hours on the river we found a gentleman sitting in a hollowed out tree trunk fashioned into a canoe. He directed us to the river branch where the patient, one of our technicos and the patient’s father were awaiting our arrival. Our technico from the nearest health post jumped into his boat and started an IV and antibiotics the night prior and was in contact with our nurse in Iquitos via a solar powered laptop and internet.  The child was waxing and waning in alertness but we arrived to Santa Clotilde that afternoon without problem.  He had pneumonia by exam and we adjusted some of his medications. On physical exam we noted swelling to his L wrist and thigh/knee. I was very concerned about the infection being in his bloodstream and entering his joints. The next morning he went on our boat with one of our nurses another 6 hours down to the regional hospital in Iquitos. He had x rays and was diagnosed with a severe pneumonia and septic joints. He stayed in the hospital several weeks, but recovered.

I give thanks for the dedicated workers we have on our river and the resources to be able to continue the work Padre Jack, Padre Moe and all the workers who elevated the level of care to be able to respond to needs of the over 300km of river we cover. God is Good.

Brian

Harold

Harold is 42 years old, the youngest of three brothers. Their parents are no longer living. Harold also has 4 children: six-year-old twins girls, a four year old and an 18 month old. His wife died just over a year ago of malaria, so he raises his children on his own, with the help of his two brothers and sister-in-laws.

Harold has had high blood pressure for years, with fluctuating creatinine´s. His creatinine (a test to see how the kidneys are functioning) had been slowly increasing. He was admitted to our hospital twice with his whole body swollen and his lungs and abdomen full of fluid. His kidneys were not able to get rid of the excess fluids. His last admission, he had a creatinine of 6 (usually once you reach 5 you need dialysis). Luckily the diuretics worked and he was able to urinate out some of the excess water and breath easier. We sent him to Iquitos where he was hospitalized at our referral hospital. He was sent back with a creatinine of 4, on the all the right meds to keep his water balance stable.

So yesterday and today, I spent a lot of time talking to Harold and his brothers about dialysis and renal transplant. Progression of kidney disease is often inevitable. Dialysis requires that he live in Iquitos, where he has no family members who could support him. He doesn't want to live hooked up to a machine two days a week, far from his community. His brothers just make enough to scrape by, selling the fish they catch and meat they hunt to support their own kids through school. They are not in a position to support him to live in Iquitos, nor in a position to donate a kidney, being that they must travel to Lima and spend many months away from their own families who are so dependent on them.

Despite the gravity of the whole situation, Harold has a constant smile on his face and the most positive attitude. The family has an immensely strong faith in God, and finds solace knowing that He is in control. We are all hoping and praying for a miracle- an improvement in his health and the return to normal of his kidney function. As you could imagine, he wants to be back in his community with his family. Once he gets there, he will continue the medicines that his kidney doctor has prescribed and also utilize plants and other natural remedies to attempt to cure his condition. Keep Harold and his children and family in your prayers!

Well I hope to be more active on my blog posting. It has been a steady start to our mission here in Santa Clotilde. We have adjusted to life as parents and physicians.  We are lucky to have a wonderful “nanny” named Zulma who is a mother of 5 herself, helping to take care of Charlie while we work.   Work is steady, our internet is not. One of our biggest challenges apart from medical work in a resource lacking setting is lack of internet. I know our family and friends back home feel the same. 

We continue to be blessed. Today at mass, Padre Roberto a Peruvian Oblate priest had a nice homily focusing on ministry and service of the leity, especially mentioning education and healthcare. We also welcomed 14 young Peruvian professionals to our river. These 14 people are doing their year of service in our health clinic and outposts for the next year and include: 2 doctors, 6 nurses, 2 midwives, 2 dentists, a psychologist, and pharmacist.  This will help provide access to care for our population in extreme poverty along 400km of the Napo river.

I would like to share the story of a recent family who came to Centro de Salud Santa Clotilde. This young family from the indigenous community Angoteros, which is 6 hours in a motor boat upriver, were referred for the delivery of their twins. A prior ultrasound recognized the babies in a transverse and breech position. They came and she received her dexamethasone to help develop the babies’ lungs in case of premature delivery. She waited patiently and finally the day came when contractions started. We entered the operating room; Toni did a c-section as I awaited with 2 of our nurses to accept the babies. The uterus was huge and then the incision….bag #1, then we identified bag #2,  bag #1 open and baby #1 a girl, crying and with good tone. Next bag #2 and baby #2 another girl……..however cyanotic and not crying. We started the rescesitation, the newborn baby girl needed oxygen to bring pink to her skin, next an IV and bolus of fluid to help with circulation. Heart sounds were normal but not much movement in the lungs. We admitted her for respiratory distress and possible pneumonia.  Started antibiotics and she maintained her oxygen levels. On day 3 still not improving much, when a new nurse to our staff, not even working 48 hours with us,  “MacGyvered” (80s TV show reference) a CPAP machine. With this the baby was more comfortable and stable, but still not improving the way we hoped. She had one tough day with several desaturations and cyanotic episodes. We decided to transfer to the hospital in Iquitos for likely intubation and prolonged ICU stay. We prepared our boat and oxygen tank and the CPAP “machine” and off went one of our doctors and nurse. After a 6 hour trip they arrived at the hospital and were greeted by Elita our nurse who receives and helps all our transfers to Iquitos. The baby was admitted and continued on CPAP, an x ray revealed a congenital defect in her diaphragm muscle with the intestines entering the area where the lung should be. Two days ago the patient, mom ,dad and sister all flew to Lima as there is no pediatric surgeon in Iquitos to operate the defect. In Lima the family was met by our patient coordinator Manuel who assists all of our patients that need higher level of care in Lima and he also manages the patient house.  The baby is in the hospital and I will find out tomorrow the plans for surgery. 

God is good and as I sat in mass this morning, it dawned on me the courage that this family has and the teamwork needed to provide care in this remote region. This family comes from a community where the majority of people walk barefoot ,speak their native Kichwas, drink their traditional drink Masato, and hold on to beautiful cultural customs. My experience here as a generalization this community tends to not want to leave their community. For them to come to Santa Cloltidle is a very BIG deal; now they find themselves in Lima a capital of 10 million people with a sick baby needing a surgery.  They have come along way, but prayers are still needed as she has a long road ahead of her. 

Brian Medernach

After being here for two months, I decided to take a call. Brian and I were here without other doctors for three days, and instead of him working non-stop, I covered. The knock on my window came at 1am. Blanca, the midwife who covers all low risk deliveries came to discuss a patient. Doctor Juan, who’s house is connected to ours, heard the knock and came to see what the commotion was about. The three of us sat on benches outside our front door as Blanca recounted that the 25 year old woman, pregnant with her first baby and a week overdue, arrived with contractions and bleeding. There were blood clots on her exam, and the baby’s heart was beating faster than normal. We all agreed that a cesarean would be the safest thing, since the patient was not yet dilated. 

At 11pm, the town power goes out, so in the pitch black, the night watchman Lenorio went to inform the nurse Lily that she was needed. We communicated by phone to the nurse Yoly who would assist in the surgery and her husband Frank who works in the lab and would check the patients platelet count before I did her spinal. 

Lenorio returned with Lily, and then went to turn on the hospital’s diesel powered motor for the surgery. It takes usually an hour to prepare the patient and operating room and to mobilize everyone, which in this case was fine because the baby’s heart rate had normalized. 

Dr. Juan and I delivered a beautiful baby boy, waited a minute before clamping the cord, and the baby was nursing within a few minutes… after his vitamin K injection and eye antibiotics. By 3am, she was back in her hospital bed with the baby lying at her side.

Helping bring new lives into the world is just miraculous! With Charlie in our life now, I relate to patients and parents with a bit of a different perspective, having experienced the joy of watching a baby grow and develop. There are so many little significant moments! 

Just today actually, Charlie was jumping up and down like he’s been doing recently in his Pack’n’Play. I watched him for 15 minutes and he tried to move from one side to the other, barely able to reach the higher curved rail. After almost falling a few times, leaning forward and catching himself with his belly on the netting, it dawned on him to take a step toward the other side. Patiently, with the wheels turning in his head, he made it all the way around the Pack’n’Play. 

On this Mother’s Day, I am filled with love and connectedness and humility. My love and prayers go out to my own wonderful mother and father and family, who carried me and cared for me and continue to care for me with the same love and concern I have for Charlie. I also keep in mind mothers here in our own community of Santa Clotilde. Although they live in poverty, fighting to feed their children, some living in fear of drunken husbands, they are blessed with the strength and love and perseverance to care for their children the best they can with the few resources they have. I remember my grandmothers, who paved the way for me and my parents. They lived through joys and struggles and though them, in some miraculous way, are the reason I am here in the Amazon today. I thank Zulma, Charlie’s nanny who cares for Charlie like he is her own, who provides him constant play and stimulation and offers us cultural and baby advice that has been invaluable.

I celebrate this day with my wonderful husband, who never tires caring for Charlie and I, who’s heart is so big that it gracefully fulfills not only his family role, but the role of Padres Jack and Moe who were mentors and inspirations to so many here in Santa Clotilde! 

Wish list: Help with a grant to build and maintain a woman’s shelter to help temper the abuses that are so common in our community

In the hospital now are 3 babies with pneumonia, a little boy who burnt his hand in hot oil, another who burnt 15% of his body with boiling water, a girl with a snake bite, another with cerebral malaria, a mom and baby we delivered by cesarean section (her third c-section). We have a woman with cognitive delays and severe anemia, one with pyelonephritis, and two patients with paralysis who have been living here because they have no place to go. My wish for this week to have a visit by a physical therapist who speaks spanish for a month or a few months. The need here is great!

Charlie is walking (with lots of support), crawling like a worm around the floor, jumping and patting his chest to the rhythm of music in his jolly jumper... or on our laps. He love to listen to music and has overcome his fear of the very loud blender. The wandering chickens, dogs, birds, occasional monkey, and tall trees blowing in the wind never cease to amaze him. He LOVES bath-time, like everyone here who's hot and sweaty. I fed him chicken liver for the first time, smashed up with boiled potato. There is not easy access to iron fortified foods here, so liver is one of the only options... He ate it. I tasted it... I taste all the food I feed him...  and did not like it. He loves mashed spaghetti, lentil soup, cream of broccoli soup, sweet potatoes, boiled plantains blended with milk, oatmeal drink, and carrots. This his is usual diet. He's growing like a weed. He smiles when he wakes, smacks his lips when he wants to eat, and laughs our loud at animal sounds. He has four teeth and has left bruises on my legs with them. Luckily I still have all my body parts... his teeth are as sharp as razors.

Pray for Margarita (a sick patient who passed this week) and here family.

Wish: allergy and lubricant eye drops, a physical therapist who speaks spanish

We have arrived in Santa Clotilde to begin our mission at the Centro de Salud Santa Clotilde. This remote hospital and clinic in the middle of the Amazon basin on the Napo River sits halfway between Iquitos, Peru and the Peruvian/Ecuadorian border. The town is about 3 degrees south of the equator. The journey is long and has taken more time than we initially thought. Our son Charlie has done well with the long trips and change in scenery from the record cold and snowy winter in Chicago to the loud busy city of Lima to the heat of Iquitos and now the 2 boat 7 hour journey up the Amazon and Napo River. 

We spent a month in Lima with Padre Mauricio working our papers to obtain a Peruvian medical license. We were happy to have comfortable lodging, good Internet connection, and good conversations along with hearty meals with Padre Moe. Padre is an Oblate priest originally from Saskatchewan, Canada. He is also a physician and served in Santa Clotilde from 1986-2008. He left in 2008 as he was elected superior of the Peruvian delegation of Oblates, for whom he served two 3-year terms as superior.

As I sat in front of the computer translating about 300 pages of medical school course syllabi and descriptions into Spanish I must admit I was not using the tools we worked on in California.  I had some bad days and became very frustrated. The jokes of Padre Moe and his recipes that Toni had the chance to perfect, and the ever present smile on Charlie’s face helped pull me from my funk.
After our month in Lima we flew to Iquitos where we stayed for 5 days making our purchases of food and appliances that we’ll need in our house in Santa Clotilde. We also met Toni’s parents at the airport as they came to visit and see where it is exactly we are taking their grandchild I write this blog from the boat as we travel up the Napo River. The sunshine is warming my arms, the breeze in our face and the river banks filled with the lush green rain forest that provide much appreciated fresh country air. I write with a smile in my face and a hopeful heart for our future serving at the hospital knowing that we are called to be where we are and that in the end everything will be all right, God is good.

Brian
02 March 2014

This last year has been life changing in so many ways. Attending Mission Doctors (MDA) Formation Program in Las Angeles for four months, living in community, living through the nausea that pregnancy brings, and celebrating our 5^th wedding anniversary consumed the first half of 2013. MDA formation was inspiring, and stretched us and our marriage to grow in ways we never imagined. 

Then, shortly after returning to Chicago, I awoke with contractions and before we knew it, our beautiful son was born…. two months early. Charlie is the most amazing miracle and he puts a smile on our faces all day. God is good! We’d like in this blog to share our joys and pains as parents, rural doctors, and as part of the interconnected web of life and love that unites us all.

Nursing, diapering, cleaning, and beholding the miracle of our little baby Charlie consumed me. I thought about how fast he’d grow, how he’d fare in the jungle, and about what to carry with us to Peru.  Over months, we prepared our bags, setting aside items to take to in Santa Clotilde. I frequently though about the many babies we had delivered in Santa Clotilde and took a deep breath knowing that even if showed up with nothing, we would find all we need in town. Despite knowing this, we do find solace in our water filter, ice cream maker, booster seat, cloth diapers, sharp knives, iPad, toys, and many of the other gracious gifts we were given to accompany us on our journey. 

More important than the bags we carry with us are the love and support of so many, and the humble knowing that we are guided always by a spirit much greater than ourselves.

While home, we enjoyed time with family and friends, indulged Charlie in his first taste of ice cream with Papa and Bets, watched as Nani taught Charlie to snap and sing Barney songs, and as Papa’s Donald Duck impression lit up his face. Grandmama endearingly read Charlie’s favorite musical turtle book to him and Grandpapa successfully changed poopie diapers, prepared bottles, and reflected back to our Charlie a smiley, bald, blue eyed image of himself. 

Charlie loves to play, to be mesmerized by palm trees, to talk to the zebra hanging  over the bed, and above all, he loves a full belly. Fattening him up after being born less than 5 pounds was not a difficult task. Our little butterball will love the jungle.  He’s starting to roll over, giggles up a storm when we tickle him, and has become proficient at shoving anything within reach into his mouth. 

Brian and I are filled with gratitude for each other, for our son Charlie, for our family and friends and their willingness to walk this journey with us. 

Antoinette