HIV + snake bites + reflections on aging

Two of our patients with HIV died in the past week.  “Iquitos is the cradle of HIV in Peru”, one of the doctors told me.

One patient was Liz, whom I wrote about in my “Transportation” post.  She was hospitalized three times with us in August and September, each time for more than a week.  Her CD4 count was low and we knew that she had tuberculosis in the brain; we hoped she could get some more diagnostic tests and maybe some stronger medication in Iquitos.   Elita is our nurse in Iquitos; she helps coordinate our patients who are referred to specialists there.  “They are just giving Liz the same treatment you were giving in Santa Clotilde!” she grumbled.  Usually,  she does not grumble; she is a very helpful person who is a terrific advocate for our patients, who are often too sick or to humble to advocate for themselves.  “But Liz needs a CT scan, she needs a lumbar puncture in a place with a microbiology lab, she needs an ophthalmologic exam because she is losing her vision and probably has parasites in her eye…”

Elita sent us a copy of the head CT; Liz’s brain volume had contracted by almost half; her ventricles had almost disappeared.  Her CD4 count was 31; she died the day before yesterday.  Elita asked for help sending the body home.  “In Lima they would burn that body, as a public health hazard, with all that resistant tuberculosis,”  Williams told me.  Here in Loreto, Hugo made arrangements to bring the body back to Santa Clotilde. “Tell the family not to open the body bag,” Elita counseled me.  I didn’t go to the wake; I didn’t know if I should.

Olmer also died of HIV this week.  When he got very sick, I asked his mother if we should transfer him to Iquitos.  She shook her head.  I was reminded that Andrew, the family doc who was in Santa Clotilde all of last year, told me that every patient that he transferred to Iquitos had died.  Olmer was only 39, but he weighed only 100 pounds.   We diagnosed him three weeks ago, but his CD4 count was very low, his kidney function was not good, and his liver was not working well enough to keep the fluid in his circulation.  Hermano Pedro came to give him last rites.  Olmer was the son of Chelita, who cooks for the nuns.  He had been estranged from the family for fourteen years.  Recently, they found out he was in Trujillo and the nuns helped pay for his transportation back to Santa Clotilde.

Ronal came to me a few weeks back; I was looking through his chart and  saw notes about his HIV meds, but the last note was from more than two years ago.  “What about the HIV meds?” I asked him.  “Are you getting them somewhere else?”  He looked at me quizzically.  “I was in the hospital but I got better and so I stopped taking my medicine; I thought I was done.”  I explained that the HIV meds needed to be continued forever.  He wanted to get started right away, but of course there is a process.  We have to get his CD4 count, and we send that test out on Mondays and Wednesdays, so the patients have to come Sunday evening or Tuesday evening to get their blood test.  Ronal was in town for the elections, but he is living in a community called Tigre, which is a four day boat ride from here.  The idea was to have his CD4 count drawn here, and then he would go to Nauta, which is about seven hours from here, outside of Iquitos.  From Nauta, they would send his HIV meds to a place called Intuto; he would then travel six hours every month from Tigre to Intuto to pick up his HIV meds.

When he first came to see us, we told him to come back on a Sunday or a Tuesday for his CD4 count.  He came on a Wednesday, so we had to tell him to come back on Sunday (and when I say come back, it is two hours via canoe to Santa Clotilde from his dad’s village and two hours back).  He came on Sunday, and we sent the sample, but on Tuesday I got a call from Elita telling me that no one had called her about the sample, and that it had sat outside of the refrigerator too long and would have to be redrawn.  We called Nauta and Intuto to let them know, but I worry about Ronal and his ability to otain the HIV meds that will save his life.

Last week we got a call from the buque, the medical boat that travels up and down the Napo, that there was a 95 year old woman who needed treatment for her snakebite.  Jergón  is the name of the deadly snake that causes hemorrhage and necrosis,  the Bothrops pit viper.  Two weeks previously, we had had a patient with a jergón bite; thankfully we have a protocol in place and enough anti-venom.  That patient recovered well, but she did need a two day hospitalization, lots of antibiotics and pain medicine along with the antivenom.  This 95 year old patient, Elia, came in oozing blood from her gums and her urine and her snake bite.  We gave her the antivenom and I asked her about the incident.  Was it a jergón?  I asked her.  Yes!  she answered.  And I killed it myself, cut it in half with my machete.  I nodded.  Something to aspire to, I thought, hacking poisonous snakes with my machete at the age of 95.

Most of the patients here look older than their age, much older.  So much sun and hard work; their lives are not easy.  I am always surprised to learn that a patient is only 40 when I think she looks about sixty.  Deep wrinkles and missing teeth and a weary acceptance of hardship.  But for the people who make it to an advanced age…they are tough!  I saw Nelly’s mom in the consultorio recently; she is 88 and has terrible arthritis and can barely walk.  She lives in Patria Nueva, about two hours away.  She wanted her cortisone shot and her naproxen to help her get along.  Nelly’s sister brought her in, but later I told Nelly that I had seen her mom.  “Yes,” she signed.  “For a while, I had her living with me here in Santa Clotilde, but she got bored and didn’t have enough to do, so she went to live with my sister in Patria Nueva where she could help out with the chickens.”    I was impressed that Nelly’s mom had made it up all the stairs to the Centro de Salud.  I keep forgetting to count them, but there must be about 80.  “She crawls,” said Nelly.  “And she scoots down the stairs on her bottom.”

Mostly all of the visits in the consultorio are quick, like outpatient clinic.  I have a lot of papers to fill out, with everyone’s ID number and birthdate and chart number.  There is not always time to ask all of the questions that help you understand a patient’s situation.  Yesterday I saw 22 patients in consultorio.  But one little girl made me tearful yesterday.  She was a beautiful little three year old girl with a sweet pink dress and a shy smile.  Her chart said, “muchas heridas en todo el cuerpo”, many wounds all over her body.   When I lifted up her dress, her abdomen and her buttocks were covered with oozing little wounds.  Her father carried a cloth to shoo the tiny little flies away.  “Fiebre?” I asked.  Yes, she had had a fever.  And lots of itching. “Will it be much longer?  We need to get back to our village; a neighbor was kind enough to bring us upriver to you, but he cannot wait for us all day and we must travel many hours before dark.”  So I gave that beautiful little perfect girl, whose life looked like it might be very difficult, some dicloxacillin for her infected sores, and an antihistamine for the itch, and some tylenol for her fever, and hoped that her dad didn’t notice the tears in my eyes.