Referencias

So there is this whole referral process that I am just starting to understand.  I was worried, when I was planning to come here, that I am not trained to do Csections and spinal anesthesia; what should I do with patients who needed a higher level of care? “Anything you’re not comfortable with, just refer,” Toni advised me.  “Just refer” makes it sound easier than it is.  For example, we had a child here recently named L___, from Rumi Tumi, several hours away by peke-peke.   He was sent to us in mid-August for a blood transfusion; his hemoglobin was 4.  He received a blood transfusion from his dad; he had a high fever for several weeks, but no localizing symptoms (no cough, diarrhea, nausea/vomiting). He stayed with us for more than a week, receiving IV antibiotics and the limited diagnostic studies we could perform.  We even treated him for malaria, although his gota gruesa  continued to be negative. His spleen was very enlarged, and we were worried about some kind of childhood malignancy.  His mom took him home from the hospital early one morning, without letting anyone know.

It was hard to communicate with Arminda, his mother; she is Kichwa; it is not clear how much she understands.  She nods and smiles.  But she brought him back to Santa Clotilde for another blood transfusion a few days ago; we received word from the nurse at Rumi Tumi that L___’ s hemoglobin had dropped to 2, a level almost incompatible with life.  His spleen was even more enlarged, reaching almost into his pelvis. We transfused him, and sent him by “emergency” river transport to Iquitos.

Marco Antonio is one of the new Peruvian doctors here.  He is in charge of transfers and teleconsultas.  In order to have L___’s transport paid for, it had to be an emergency.  He talked with the pediatrician in Iquitos, and we decided to use “hypovolemic shock” as a diagnosis worthy of emergency transfer.  After all, his hemoglobin was 2 when he arrived, although it improved after the transfusion.   Neoyorquina is a tecnica who has been here for more than 30 years, and she helps arrange the transfers.   “Clearly, the child needs to go to Iquitos.  But if you go around inventing diagnoses, they will never pay for the gasoline!”  Heiner, one of the SERUMista doctors who is working in Tacsha, did us the favor of accompanying L___ to the hospital in Iquitos and making sure all the paperwork was in order.  We put three diagnoses:  1) hypovolemic shock 2) severe anemia 3) recurrent fever.   “The referral has been rejected,” Neo informed us.  “You put the diagnoses in the wrong order.  It should have been 1) shock 2) recurrent fever 3) severe anemia.”  Fortunately, Heiner had brought some blank referral forms to Iquitos to submit corrected versions.  We are already in debt many thousands of soles for gasoline.

Today, we received a phone call from San Rafael; there was a one month old baby with fever, respiratory difficulty, cyanotic.  Would we pay for a river ambulance to go upstream and pick up the baby and bring him back?  Of course.  But when Gabel the licenciado went to pick up the baby, he was fine.  Fever, yes, but breastfeeding well, not cyanotic at all.  But they did not feel comfortable managing him at San Rafael, so they exaggerated his symptoms so that we would pay for the gasoline and come pick him up.

More about the Kichwa:

Melanie, the lovely young doctor from Holland, went to Angoteros with Jimmy the musician-turned doctor.  He is doing his SERUM year in Angoteros, 12 hours upriver from here, closer to the border with Ecuador.   Melanie saw many Kichwa families: women dressed in colorful skirts, shy children who don’t learn Spanish til they start school. Lots and lots of malaria. People come to the health post only when they have a fever. One little six month old baby girl came with a huge growth on the side of her eye; she came two hours downriver to Angoteros to get it looked at. Maybe a hemangioma? But she did not have it when she was born. Leishmaniasis? Maybe. But the treatment is 21 days of IV medication, and the family is not willing to travel so far. And even less to Iquitos, to have a specialist look at it.

Some things about the Kichwa culture remind me of my time on the Navajo reservation in New Mexico, while I was in residency.  I wanted to honor their culture and I felt bad about the genocide of their culture, but it was hard to reconcile my admiration for their long-ago culture while confronting their present-day culture. And the Kichwa drink a lot of masato, and leave their children some in the home all day while the parents do their farm work in their chacras.  And there are pregnant girls of 12 and 13, and children who are remarkably quiet, and not much the SERUMista can do to win the confidence of these people whose language he does not speak, and who will be replaced in a few short months with a new SERUMista.

Have I talked about masato yet?  It is the local alcoholic drink, made of yuca (cassava), which is chewed up by a grandmother and spat out, to ferment.  It is supposed to be very strong and taste horrible; I have not yet had the pleasure of trying it!

I just finished a book called “The Lost City of Z”, which tells the story of a famous explorer of the Amazon named Percy Fawcett, who disappeared in 1925, looking for the a fabled lost city in the middle of the jungle. It was a fascinating book, talking about one of the last of the great explorers, and about the Amazon region back at the beginning of the 20th century.  No one every found Fawcett’s body, although many subsequent explorers lost their lives searching for him; in the end it seems like he may have been killed by hostile Indians.  It is not surprising that the Indians were hostile. The rubber barons captured and enslaved many thousands of them, to help harvest the rubber from the jungle. Many thousands more died.  There are some fancy old buildings in Iquitos built during the rubber boom, but the rubber boom collapsed when some enterprising fellow smuggled rubber tree seeds out of the jungle. Rubber could thus be outsourced to cultivation in orderly farms in colonial Asia rather than battling mosquitoes, pit vipers, and malaria in the Amazon.

No, it is not surprising that Indians were hostile to Percy Fawcett’s group of treasure-seekers, and not surprising that the Kichwa do not look to outsiders for medical advice.

But in the end, Arminda was willing to bring her child to Iquitos.  I accompanied them to the dock, to wait for the Orlando and the river ambulance.  “Have you told your husband that you are taking L___ to Iquitos?” I asked her.  She shook her head.  I thought her husband should know; they might not be back for some time.  They might get sent to Lima.  Rumi Tumi does not have phone service.  There is one land line, close to the school; if you call the land line, someone might pick it up and go to look for the person you are calling.  No one answered at Rumi Tumi, so I wrote the number down on a scrap of paper, hoping that Arminda could call her husband sometime soon.

The next day, I received a call from Elita, the nurse in Iquitos who helps us coordinate our referrals.  “M___ has died,” she told me.  M___ was a 74 year old man with a surgical abdomen whom we had transferred to Iquitos the previous week.   The surgery was long, and he died a few days later.   I called Orlando, the driver of the ambulance, and asked him to stay in Iquitos until the body could be released, to take the remains back to Santa Clotilde. It is difficult, and expensive, to transport a dead body.  When Orlando returned to Santa Clotilde, I thanked him.  Did you know M___?  I asked.  We have been friends since childhood, he told me. I thought about how strange it must be, to bring the body of your childhood friend six hours upriver for burial.