A doctor fights to save an indigenous girl who was complicated by malaria in the Venezuelan Amazon.
The first time that she came to the doctor’s room, she was scared. She was a fifteen-year-old indigenous girl. She came with fever, headache, and lumbar pain, the same symptoms her father had before dying. He didn’t want to come to the ambulatory medical center, he didn’t trust in the medicine of the creole people, the ones who aren’t indigenous. The girl saw how her dad got worse lying down at a hammock, in the churuata (indigenous house) where the whole family lived. When the community’s captain realized that the mister was in bad condition, he carried him to the town’s hospital, but there wasn’t a treatment for malaria. That’s why the girl asked to be brought to the ambulatory medical center as soon as she began to feel bad.
I’m not going to tell you about her ethnicity nor where she lived and don’t write down the name of the ambulatory medical center, nor the zone where we are. We don’t want any trouble with the communities nor with the government. I just will tell you that this case happened in the south of Venezuela.
Her name was Mate. I spoke to her in her language but she didn’t even look at me in the eyes. I had ten months as a rural physician in the zone and I passed medical consult in her language, but women in her ethnicity didn’t speak because the man was the one with the face and voice of the family. When they came to the medical consult, one asked the dad, the brother, or the husband what was wrong with the patient and he answered for her. I told Mate caimac, aitäna nkotopak. Hello, where does it hurt? She didn’t answer.
Mate and her family lived in a community where we had a focus of Plasmodium falciparum, the parasite species which causes brain malaria and most paludism deaths. I made her a thick drop test and the result was Plasmodium vivax, the most common species, the one that usually doesn’t generate troubles. The indigenous people call the vivax, dumb paludism because many of them are infected with it but it doesn’t affect them too much. I ordered her primaquine and chloroquine, she should get cured with it. The captain of her community said that he was going to give her the tablets to fulfill the treatment. The captains know that when there is a case of malaria in their communities, they have to attack it as soon as possible to avoid difficulties.
Ten days later I had to go to the town’s hospital, a hundred and sixty kilometers away, to report the monthly record of the ambulatory medical center’s patients and get medicines. I left at six o’clock in the morning to arrive in town before eight o’clock. I wanted to get back at midday and pass medical consult in the afternoon, but we had troubles with the car inside the jungle, we didn’t have any phone signal and the guys repaired the station wagon after some hours. We got back little by little and arrived at the ambulatory medical center at six o’clock in the evening. We hadn’t eaten anything, we were really tired. As soon as we crossed the entrance gate, the watchman’s wife told me: “Doctor, there is a patient who is in bad condition, go there because she is sick.”
When I arrived in the waiting room, I saw Mate leaning on the white chairs. I told her to come to the doctor’s room and a cousin took her in his arms and seated her in the gurney. I got surprised because she couldn’t walk. I greeted her in her language but she didn’t raise her gaze, she didn`t say a word. Since she was accompanied by a cousin and a woman, they translated. I asked them if she had had a fever and they told me that it had disappeared with treatment. The problem was that she couldn’t walk. I hit her with a little hammer at the knee’s tendon but she didn’t move the legs; she also didn’t have reflexes at the ankles. I asked them if Mate had eaten or drunk water and they told me that no. She had trouble swallowing. The cousin told me that the day before, Mate had said incoherent words. The watchman’s wife saw her rigid before my arrival, maybe she had convulsed. Then I decided to make her a deeper physical exam.
I passed a little light on Mate’s eyes and the right one didn’t follow it. It was hard to make her understand that she had to move her eyes, I twisted my fingers at her sides to call her attention but she had troubles moving her right eye. Her tongue was diverted to the right. When I touched her abdomen, I found a bladder balloon, her bladder was at full capacity. I asked her to stretch her right arm and touch her nose to see if she could coordinate, but she couldn’t do it. The blood pressure went up and down. There was a parasympathetic dysfunction; the part of the central nervous system that makes us sweat, urinate, or defecate didn’t work well. Mate had neurological damage.
The symptoms indicated difficult malaria and at the ambulatory medical center there wasn’t artesunate intravenous, the first line of treatment suggested by Ministerio de Salud and the OPS (Health PanAmerican Organization) to treat this type of case. We had artemeter intramuscular, the second line of treatment.
We had been many months without any antimalarial medicine. The hospital’s main office gave us the medicines for the ambulatory medical centers of the zone, early in the year. But afterward, the government delegated the distribution of the treatments in the military corps. Then the hospital’s director had to go to the Army commanding office to get the medication doses. In that new procedure, they didn’t include the ambulatory medical centers and we stopped receiving the treatments. When the physicians of the ambulatory medical centers informed us about the situation, they told us that we had to go personally to retire the medication doses each time we had a patient infected with malaria. That delayed the treatment about fifteen days because we were far away. I attempted to do it, I went four times to the Army commanding office and they never gave me the antimalarial medicines.
One day an indigenous person died at the hospital because they didn’t have any medical treatment. Then many indigenous people from all the ethnicities of the municipality protested in front of the hospital. Thanks to that they changed the distribution scheme and allowed that the patients and even the captains of the communities would retire the antimalarial medicines. The one who died was Mate’s dad.
Since I wasn’t sure if the artemeter was enough to treat Mate, I decided to ask for a second opinion and wrote by Whatsapp to an internist physician who had made her rural internship in the same ambulatory medical center. I told her about the symptoms and antecedents of the case. She recommended me to hydrate Mate to give her some strength because she hadn’t eaten anything and I confirmed how to prepare the artemeter shot. The internist believed it was difficult malaria, she had read about brain malaria by vivax and not only by falciparum.
The internist suspected that Mate could have the syndrome of Guillain-Barré. That is a strange disease that is activated by an infection or a medicine. The brain transmits electrical signals to the muscles through the nerves, which are protected by a substance named myelin. When there is Guillain-Barré, that layer is destroyed and the nerves don’t work, don’t transmit the electrical signals and there isn’t muscular response. That’s why Mate couldn’t move her legs, nor the right eye, nor could swallow nor urinate. If she got Guillain-Barré, she was a critical patient and must be in intensive therapy treated by specialists. Not in an ambulatory medical center with general physicians. Mate was at risk of dying.
I tried to call several services of an aero ambulance but I couldn’t communicate with them. The phone signal was too weak. I asked the internist to call from Caracas while I inserted a foley to Mate, a catheter to take out her urine. The one she had was very thick for her. For girls so young we use to use a smaller foley but there wasn’t anyone. I tried to insert the catheter. I couldn’t. I went out of the doctor’s room and breathed deeply for some minutes. I came back and could insert it. I took out a liter of urine from her.
The internist got in touch with four services. Two helicopters were far away from the zone and one plane was translating a patient. The last pilot she contacted told her that they could go for Mate the next day at the town’s hospital if we arrived early there.
It was already midnight and we had two options: carry her in the car with failures or wait until the next day. With the first option, I risked that we stayed broke down without the basic support measurements to keep her stabilized. I worried about Mate having a respiratory failure because respiration is also a neurological process. If that happened we would have to tube her. With the second option, I risked that we couldn’t fix the station wagon on time and Mate could collapse before arriving at the hospital. I woke the driver up, I told him about the situation and he told me that for the first time in the morning he would find a way of repairing the station wagon. I got back to the doctor’s room, sat on the stretcher by her side to monitor her, and slept for two hours.
At six o’clock in the morning, I checked her vital signs and Mate was in steady condition. I poked and saw the driver of the ambulatory medical center with half his body under the station wagon’s hood. At eight o’clock her blood pressure increased and I told the driver that we couldn’t wait anymore. As the cousin helped me to get her in the station wagon, I repeated her capanaoki, kapanaoki. Calm down, calm down. For the first time, she looked at my eyes and talked to me in her language. “I don’t want to die”.
We arrived at the hospital at ten o’clock in the morning. The plane had gone to look for a patient in serious condition at another hospital. I gave the case to a resident of the Universidad de Oriente who I trusted. I suggested she make another thick drop test to prove if she had mixed malaria, maybe she also had falciparum and that’s why she had worsened. But the result was vivax again. I told them that I thought it was the syndrome of Guillain-Barré and they agreed. There was a malaria specialist who knew about the case and suggested sending her immediately with an intensive care specialist to Ciudad Bolivar or Puerto Ordaz. I stayed until noon but I must get back. The ambulatory medical center was alone.
On the way back I didn’t have any phone signal to ask about Mate’s condition. We arrived at the ambulatory medical center at about two in the afternoon. When I connected again, I got a message from the resident. Mate made Kussmaul, the respiration previous to death. I sat to cry in frustration. That girl didn’t have to suffer because of a disease that had been eliminated so long ago. Some hours later, the resident informed me that Mate had died.