Lo-Tech, High Touch in Amazon Medicine

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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 taps 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 said gamely. “Which house?”

They point me to a 10-foot board set up across a void to connect the “clinic” to another family home. I quick-step along the board, entering the family home—bare of furniture except for a small table with a pot and a few small chairs. A 70-pound, very old woman (96, according to the family) is lying on her side on a cotton blanket. The family tells me it has been a month since she was able to sit up or stand. “She doesn’t like being touched’ they say. I kneel on the floor at her side, and speak to her in Spanish in soothing tones. “She’s pretty deaf,” they say. But she hears something. I hold hands with her, and she turns towards me. Strong grip. Moves 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, I think, “Wow. No decubiti. Her body is clean as a whistle.” The family says they bathe her twice a day.

We have a SonoSite, and our patient allows a cursory FAST-type check. We find nothing amiss. I stand up. “Thank you for letting us examine your grandmother. What do you think is wrong with her?” I say. “Old Age,” they reply. I nod respectfully. “You are right—And you have taken good care of her. She is lucky to have such a wonderful family,” I say.

Another World
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.org in February 2017 on a medical trip into the Peruvian jungle.

AmazonPromise is a small-but-complex 25-year-old NGO headquartered in Massachusetts and Iquitos, Perú. It operates a clinic in the Iquitos stick 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 adventures are based at the Yacumama Lodge, on the banks of the Yarapa River, a full day trip from Iquitos. AmazonPromise also employs about 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 require a day or more of travel in an open Amazonian dug-out. What health care there is in Iquitos, especially specialist care like ophthalmology, is pay-as-you go, making matters much more difficult.

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 their seventies and eighties, 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 begin 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, is it HOT! There’s no fan, no cross-ventilation breezes. Sweat starts on the chest and back, and then forms around your neck, ears, and scalp. Eventually it drips down your forehead, fogs your glasses, and stings your eyes. Note to self: Next time, bring a sweatband!

We have a dentist, a humanitarian Peruvian GP from Iquitos, and a laboratory. But here’s what labs we can get: malaria smear, acid-fast for TB; POC glucose and Hgb; u/a; pregnancy test; HIV screen. Our meds were basically repurposed or donated from relief organizations. 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. Another note to self: Next time, bring favorite medical handbooks.

The caseload is mostly the ambulatory type. Many children. Several cholesteatoma. Lots of vision problems, mostly cataracts and pterygia. Despite the blazing sun, no one can afford sunglasses. One woman with glaucoma can’t afford her eye drops, nor can she get to Iquitos even if she had the funds to buy her meds. All I can 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 seems fine.

Next, a baby with scarlet fever. I haven’t seen that since med school, and none of the other faculty, students, or residents have ever seen it. (Age has its advantages.) Next, children with rashes after swimming in the river. What could the rashes be? I think one rash is bullous empitigo. Next, a pregnant woman with new onset migraine. Then, a seven-year-old boy with fever but no exam findings—UTI!

There are lots of complaints of dizziness. Even in the older population, this always turns out to be dehydration, identified through symptoms or BP check. Only one child complains of dizziness. This 11-year- old boy worked in the farm all day, starting in early morning until about 1 p.m., but had no water to drink. We supply his mother with WHO rehydrating solution packets and give the family a few bottles of water.

Another mother brings in her newborn, a 30-day-old boy with vague chief complaints: sleepiness, occasional cough. We breathe a sign of relief at the 30-day age, but the infant looks rather scrawny, and he looks listless even while sleeping. Fever? No. Eating well? Yes said the mother. No other disturbing symptoms. We have the mom wake up the infant and breast-feed. No retractions, no grunting. Improved responsiveness. What to do? Our only tools for diagnosis are our clinical skills. I decide to give the neonate Ceftriaxone. We give it IM, and it results in healthy cries and better energy. More antibiotics? No, that would be a stretch as he looks better. We check him at the end of the day, same scrawny baby. The location of the village enables another follow-up check in 36 hours. The neonate appears okay. We all breath a sign 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 make the right decision. No further antibiotics.

One clinic day, we are called to see a 22-year-old woman with knee pain. She can’t walk. Would we go to her home? She has knee and ankle pain and thought she must have sprained her ankle, though she couldn’t recall doing it. On exam, she has a knee effusion. We tap 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. We are looking for abnormality,” I say, “And this is it.” What are our treatment options? Not much. We opt for Ceftriaxone, which could be given IM with lidocaine x seven days; and then po Clindamycin as long as the med held out, hopefully four weeks. Follow-up? Likely six months later.

A quiet Night?
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 sauteed plantains for desert are followed by quiet conversation and reading by headlamp.

Then suddenly – what’s that calamitous noise?

One of our indigenous workers has come in the black night in a dugout canoe with family and grandmother. The grandmother is moaning in pain. The family carries her into the entryway and places her on a padded weight bench (that must have been placed for just this purpose). I check her and identify 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 start an L of normal saline and obtain history from family as best we can. Just sudden onset of abdominal pain.

I am careful to work respectfully and as a team with Dr. Luis, our Peruvian GP. He confidently orders IV nexium and IV hyocyamine for the patient. Hyoscyamine? Nexium? Hyoscyamine seemed to ring a bell, some type of anticholinergic. Dr Luis said it is great for GI spasm. I think she has acute diverticulitis, and conferring with Dr Luis, I add IV Ceftriaxone to the therapeutic cocktail. We have only oral flagyl. “Wait to give any po meds until her abdomen has calmed down,” he says. In less than 30 minutes, her pain abates, and LLQ pain diminishes. Sonosite is helpful to rule out leaking or ruptured AAA, but mostly it helps by calming us modern techno-dependent doctors. We are pleased to identify a GB stone, but she has no RUQ tenderness. We do not identify any free air. It would be 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 caymans ready to swamp our boat in the Amazon. So—as she was improving, we give her 1 gm po flagyl, continue IV saline, and keep her on the weight bench for the night. Dr. Luis is very happy to check on her intermittently. Our wake-up conch sounds at 7 a.m., and I rush to the weight bench. There is our patient, eating an orange, hungry, no abdominal pain, ready to be canoed back home! We have her continue three more days of po cipro and flagyl, just in case. But I re-learn 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, and 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 that 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 change roles and become my usual self again: tertiary-care ER doc. I feel 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. There are great benefits from technology, but are we losing the ability to think, analyze and remember without common technology tools?

I take a breath, step back, and try to move my technology curve backwards a bit.


Further 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: AmazonPromise.org Malecón Tarapacá 322, Iquitos Perú. Rosa is English speaking 965-000-064

ABOUT THE AUTHOR

EDITOR-IN-CHIEF
Dr. Tintinalli is currently a professor and Chair Emeritus of Emergency Medicine at the University of North Carolina. In addition to teaching in the emergency medicine department, she is an adjunct professor at the UNC Gillings School of Global Public, and a frequent lecturer in the School of Journalism and Mass Communication. Dr. Tintinalli is double boarded in emergency medicine and internal medicine. She was the founder and first president of the Council of Emergency Medicine Residency Directors. She is a former president of ABEM as well as the Association of Academic Chairs in Emergency Medicine. She is a past winner of ACEP's James Mills award as well as ACEP's National Education Award. And of course, she is the Editor-in-Chief of 7 editions of her eponymous textbook, which is arguably the best-known EM text in the world.

1 Comment

  1. Dear Dr. Tintinalli,

    You wrote: “Our meds were basically repurposed or donated from relief organizations. 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. Another note to self: Next time, bring favorite medical handbooks.”

    As an emergency physician who spent a year working in remote medical sites in sub-Saharan Africa, I’d highly recommend the Oxford University Press series: Primary Surgery (vol 1 and 2). They provided me with indispensable step-by-step instructions on everything from dental extraction to caesarian section. I’d often prop them up in the operating rooms where I worked, sometimes by light of a kerosene lantern, to make sure I got the steps right. I’m no surgeon but successfully saved many women with ruptured uteri and one elderly man with a perforated duodenal ulcer.

    You also might be interested in the similar-themed “Anesthesia Off The Grid” that I recently published for humanitarian and mission physicians going to remote areas to work as a Kindle book. Short, succinct, and gives instruction in things we never learn in the US but may be essential for practice in areas without internet, power, monitors, or oxygen: spinal anesthesia, ketamine drip, succinylcholine drip, local anesthesia for major operations, and the like.

    These indeed were the norm where I worked. Sounds like you had the same environment in the Amazon.

    Thoroughly enjoyed your piece. It brought back wonderful memories of my own.

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