singing the Peruvian national anthem in Kichwa

Last week, Declan led his class in singing the Peruvian national anthem in Kichwa. I told him that his college admissions application is now complete: “…when I was ten, I led a group of fifth graders in the Peruvian Amazon as they sang the national anthem in Kichwa…” It was really sweet. Like many indigenous languages around the world, Kichwa is disappearing. Peru is apparently trying to make sure that it stays alive, with more bilingual Kichwa/Spanish teachers, and teaching some Kichwa in schools. Declan was nervous, but he did really well, using his violin bow to conduct the class. His violin is trashed. The humidity broke it once, and Paul Ghent fixed it with wood glue and clamps, but it broke again shortly thereafter.

Dr. Andy was with us for almost three weeks, which was such a pleasure. He is a family doc with Csection training, and we were able to do a Csection while he was here, my first since arriving at Santa Clotilde. I have been amazed at childbirth here. None of the women receive any pain medications; most of them arrive when they are close to ten centimeters dilated, and all of them breastfeed without fuss. Once, when I first arrived, there was a young girl whose labor was taking a long time and who seemed to been in a lot of pain. I suggested a little bit of morphine to let her relax a bit and allow the labor to progress; everyone was really nervous about giving morphine and it was clearly not the norm.

Wendi is the sister of our tecnico Jens; she had been in labor for a long time but was stuck at six centimeters. Andy was very comfortable doing the Csection, but none of us had done spinal anesthesia. When Toni was with me, back in August, she had placed her hands on the back of my hips to show me where to put the spinal needle: “just put your hands on the iliac crest, and where your thumbs touch one another on the patient’s back, that’s where you put the spinal needle.” I know that spinal anesthesia is a learnable skill, that it is not rocket science, but still I was nervous. I read up on it before the surgery, but still the needle did not go in the right space. Everyone was in the OR, expecting the spinal anesthesia to go well; I felt like a fraud. I asked Andy to try. He was not successful either, so we proceeded to do the Csection under ketamine. Ketamine is a horse tranquilizer that produces a dissociative anesthesia. It is sometimes used recreationally in the US. I had helped out with two ketamine procedures while Toni was here: one fracture reduction and one D&C, and in both cases the patient moaned throughout the procedure. They were fine afterward, but I was not looking forward to having Wendy moan throughout her Csection.

But Jaime did a great job with the ketamine. Jaime is a PA from Connecticut; he was in the military for ten years, in Afghanistan and Kuwait, and now he does surgery in New England. He is here in Santa Clotilde for seven weeks. He pushed in 7 ml of ketamine for induction, and then 2.5 ml every 15 minutes, just as she started to moan again. I was in charge of taking her blood pressure and pulse every few minutes, and whispering in her ear, telling her that everything was going to be just fine. The Csection went fine, and Wendi’s family made dinner of chicken soup and boiled plantains for the whole surgical team.

We had a patient arrive recently with wet gangrene of his fifth toe. The flesh was rotten and it needed amputation; Andy and I looked through some surgery books to figure out how exactly to do the disarticulation and how we should do the regional nerve block for the anesthesia. While we were debating about when we should do it and exactly how we should do it, Lili summoned us to the topico: “revisen mi curacion!” She had done the whole disarticulation and amputation with a little bit of lidocaine.

“We are in the season of butterflies,” Dayana told me, on my walk home from the domestic violence workshop. And indeed I have walked through clouds of butterflies, difficult to photograph. The domestic violence workshop brought together apus (chiefs) and leaders from communities all along the Napo River, to talk about what was working and was was not working in terms of a community approach to domestic violence. The opening remarks were in Kichwa, and a school group from Lugape to perform the traditional Kichwa masato dance. I got to try masato! Because the communities are many hours by peke-peke from the police and from the courts, the apus try to solve things locally. The “agresor” gets 3 chances of “justicia comunal” before they move to “justicia ordinaria”. I was interviewed by the domestic violence film crew, a Oaxacan woman living in Lima.

There is domestic violence, and then there many young pregnant girls. We sent a 12 year old girl to Iquitos the day that Andy left; now that he is gone, we will not have anyone capable of doing a Csection for awhile. She may be able to have a vaginal delivery, but her baby might get stuck, and if that happens in the middle of the night, there is no way to fly her out. Rosario was kicked out of her house for “coqueteando” her stepfather. Her stepfather tried to rape her on numerous occasions; at the age of 11, she took up with a 27 year old man. It seems that this man treats her well, that the sex was consensual, butshe was reluctant to go to Iquitos, in part, because if her partner is caught, he will be arrested.

Lili and Neo thought that Andy should have just done a Csection before he left, just to avoid problems with the authorities in Iquitos. Andy was reluctant; although her dates make her 39 weeks pregnant, her ultrasound showed 34 weeks; it would not be a good idea to section her too early. It was interesting the different reactions from different people. Jefferson, the biologist, asked me why I was sending her to Iquitos. This is normal for people in the community. Let it be resolved by the Apu in her village.

Even Neo said, this man is her marido, her esposo. If you send her to Iquitos and he gets arrested, he will abandon her and her life will be difficult.

I paid for her trip to Iquitos. I had gone down to the dock just after 5 AM to say goodbye to Andy. She appeared at the dock at 5:30: alone, with her backpack, ready to go to the big city accompanied by an American doctor she’d just met. “She’s making a good decision,” said Andy. “Actually, she has made a number of good decisions for herself, starting from when she escaped from her abusive stepfather.”

Different ways of looking at things here as compared to Iquitos, different here compared to the communities. Jimmy brought a baby last week from Angoteros, a 3 month old baby who weighs 2.8 kg.

Apparently the mom’s breast milk never came in; she has been feeding the baby masato. Jimmy and Limber took the ten hour boat ride to Santa Clotilde to get the baby some formula and some medical attention. Jimmy told me that she was the first mom with a starving baby that he had been able to convince to make the trip; others just shook their heads and left with their babies, never to return. Jimmy told me that many babies get accustomed to masato, that it calms them. Not unlike giving a baby a bit of whiskey, I suppose, but Jimmy told me about one mom who gave her baby some Haldol to help it sleep, and the baby never woke up. Haldol is a strong anti-psychotic; who knows how that mom acquired Haldol, in a remote Amazon town where formula is not available, not even at the health center.

60 gallons of gasoline to get to here from Angoteros, all for a lack of formula in Angoteros. Long ago, a read a book called Jamkhed, about a clinic in rural India. A husband and wife team of doctors lived there for many years and implemented many life-saving strategies, but most of them were not strictly medical. “When you build a fence at the top of a cliff, you feel more like a carpenter than a doctor,” Dr. Arole said. But you save more lives building a fence at the top of a cliff than running an ambulance service at the bottom of the cliff.”

The baby was more than just malnourished; the baby was sick. His kidney function deteriorated, and he had a high fever. We sent him to Iquitos, but he died shortly afterward. He was intubated and dialyzed; when they started the peritoneal dialysis, they saw pus: he had a bacterial peritonitis. Afterward I felt bad about having sent the baby to Iquitos; none of the doctors here felt comfortable managing a tiny baby who was so sick, but when a patient dies, there is the difficulty of figuring out how to transport the corpse. I spoke to Elita, our nurse who coordinates things for our patients in Iquitos. “Is there any movilidad from Santa Clotilde that could take the cadaver back? Vichu will not transport the cadaver,” Elita told me. Lili and Neo advised, “the baby does not weigh much; Vichu does not have to know; just wrap the baby up.” But Elita declined the suggestion. “I have already asked Vichu to take the cadaver of a baby; I cannot call them now and tell them that the mother will be traveling with a certain package. I have been denounced, in the past, for doing just that, and I will not go through that again.”

So maybe Jimmy should not have convinced the mom to bring her baby from Angoteros to Santa Clotilde, and maybe we should not have convinced the mom to take the baby from Santa Clotilde to Iquitos. Maybe the baby should have died quietly in Angoteros, like those other mothers who did not listen to Jimmy. But it is so hard to tell a young mother that her baby will die from malnutrition; we all hope we can save this baby.

It turns out that we had a trauma patient who needed our ambulance to go to Iquitos last night, so I called Elita with the update. She talked to the funeral home to have them treat the tiny corpse with enough formalin to last the two-day trip upriver to Angoteros. “Don’t open the coffin”, she told me. “You will get sick.”

So tonight we will await the arrival of the mother, and the little coffin. They will travel upriver tomorrow to Angoteros, along with the little four month old baby who came to have her positive HIV test confirmed by Western blot. She, too, is tiny; four months and just four kilos, but she is alert and very cute; we have to make sure to coordinate all of the logistics of sending HIV meds, in syrup form with the correct weight-based dosage, upriver every month.

I think this is Declan’s college application…