Surviving the Extremes: A Doctor's Journey to the Limits of Human Endurance (6 page)

The machete had cut the radial nerve, the one supplying sensation to most of the back of the hand. It’s the least important of the three hand nerves, because it’s the two on the other side that provide feeling to the palm and fingertips. Nevertheless, it would be a nuisance for a seven-year-old boy to go through life not feeling anything on the back of his hand. Worse, the cut end of the radial nerve often grows into a neuroma—a ball of raw nerve endings so exquisitely painful on contact that I’ve had patients in New York whose arms couldn’t be
touched by a sleeve. I didn’t want to have a patient in the jungle whose hand couldn’t be brushed by a leaf.

Nerves are like wet noodles when they are cut; the ends just lie there. A tendon is like a rubber band; the end attached to the muscle snaps back and the surgeon has to go in search of it. I used a scalpel to cut farther up the arm until I could see the retracted ends, then grabbed each of them with a clamp and pulled them back. There were no frayed edges. The razor-sharp machete had made neat slices. The repairs would be relatively simple. I breathed a little easier.

From the array of packets spread out on the plastic, I selected a suture strong enough to counteract the tension in the tendons and loaded it onto my needle holder. For each tendon I sewed in and out through the centers of the two cut ends, then cinched the ends together by pulling up on the stitch and knotting it. The first one came together nicely. So did the second, third, and fourth. With a much finer suture, I then made a running “hem stitch” to smooth the edges of the repair. Tendons have to move inside the arm—they can’t get hung up on the tissues they’re supposed to glide past.

I was satisfied with how it looked, but I needed to see how it worked. To test the repair and also, I must admit, with an eye for the dramatic, I asked the boy to try to move his wrist and thumb. He lifted them right away with no problem. Amazonian “oohs,” “aahs,” and “wows” arose from my audience.

Tendons need to be smooth on the outside. Nerves need to be smooth on the inside. They don’t heal in the same sense that other tissues do. When a nerve is cut, its outer tube, the epineurium, has to be reconnected, but the inside part, the nerve fibers, will degenerate. For a nerve to work again, new nerve fibers have to grow through the repaired tube. The fibers look for any excuse not to grow; hitting up against a piece of suture in a repair site is often reason enough. For nerve repairs, I ordinarily use a suture so fine that it is invisible to the naked eye, but not having a microscope handy, I had to settle for a stitch I could see. Though it was finer than a human hair, it made for a relatively bulky repair. But even if it failed and the back of the boy’s hand remained numb, the reconnected tube would at least contain
the nerve end, making it unlikely to grow into a neuroma. All in all, the repair looked pretty good, though I had no way to tell whether it would have passed the kind of meticulous microscopic inspection I would have performed in a hospital.

Hermanigildo started to get fidgety. Until then, I had never seen a nonsedated patient tolerate a tourniquet for more than half an hour. This one had already been on well over an hour. His jungle training, adapted to the exigencies of surgery, had served him well, but he was reaching his limit.

The artery, veins, and bone were still unrepaired. I planned to leave them that way. The radial artery, on the thumb side, is one of the two main conduits of blood into the hand. Either conduit is enough to provide adequate blood flow, and in fact the ulnar artery, on the pinkie side, carries even more blood than the radial. People who try to commit suicide by slashing their wrists rarely succeed because they always start on the thumb side and then lose their nerve. They would have a better chance of bleeding to death if they began on the pinkie side. Repairing the radial artery wasn’t necessary, though I would have tried it if I had more time. Even if I had all the time I needed, I wouldn’t repair the veins. The hand has dozens of them, yet a few are enough to maintain adequate outflow of blood. I would have repaired an important vein, but the ones cut here didn’t even have names. And as for the bone, it was deeply gouged but still intact. A simple splint would do.

I quickly tied off the artery and veins to prevent heavy bleeding when the blood rushed back into them. All that remained was to close the wound. I didn’t need to see inside to sew the skin, so I released the tourniquet—to Hermanigildo’s immediate relief.

Bill asked someone to bring him a tennis ball from his gear bag. He always brought tennis balls to the Amazon, he told us. They make great toys for the kids. Sure enough, our patient became totally preoccupied with the ball—rolling it up and down over his face with his good hand—while I finished sewing and applied a bandage, splint, and sling. As soon as I was done, the boy got up. I tried to get up too, but quickly learned that this is not so easy when you’ve been on your knees in the mud for over an hour.

Though our expedition was now behind schedule, the plan remained to move the rest of our supplies today to our research camp, already set up by the crew in a clearing they had made along the lakeshore. While the others reloaded the canoes, I packed up my tackle box and ate some bananas offered to me from the crowd. Then I slipped behind one of the huts to strip down and wash off my coating of mud using rainwater from the open collecting drum. As I neared the drum, I saw a bloated, decaying rat floating inside. This was the water I had just used to clean Hermanigildo’s wound. I decided I wasn’t so dirty after all.

Counting out a two-week supply of antibiotic pills, I told Berullio to have his son take one a day until they were all gone. I explained how to change the bandage and wash the wound with rainwater—
fresh
rainwater. Sebastian translated everything for Berullio, but a little girl about ten years old was listening very intently and I got the distinct impression she would be the one taking care of Hermanigildo. His mother didn’t seem to be around, or didn’t bother to identify herself to me, perhaps because taking care of children is child’s work.

The canoes were ready. Sebastian and I stepped inside. Berullio nodded one more time that he understood everything I had said but he hadn’t asked any questions. Nor did he show any gratitude, though I was sure he was appreciative. The villagers lined the beach to watch us leave. As we pulled away I could see, on top of the mud bank, a boy with a sling on his arm chasing a tennis ball with his friends.

“What if you hadn’t been around?” was the question on everyone’s mind as we glided across the lake. My answer surprised them all. To a human body, I explained, a machete cut is not much different from an animal bite. The design of the hand and arm has been refined over thousands of years to absorb a blow like that and keep on going. A human with his arms at his sides or in front of him, or an animal with its front legs on the ground, is naturally positioned so that the most vital and vulnerable structures are on the inside, behind the bones, protected against an attack from the front or side.

Had the machete cut (or animal bite) destroyed every structure on the outside of the arm, the victim would be unable to lift his wrist and fingers, but he could still bend them, since the tendons and muscles
that perform those functions are located on the inside. Though the victim would lose sensation on the back of his hand, he would retain it in the palm and fingers because those nerves are also located on the inside. He would bleed heavily from his veins. Because there are so many of them, however, the loss of a few is easily tolerated. There are only two main arteries, but both run deeply on the inside. Unless the blade or the attacker’s teeth are strong enough to break through bone, the victim can survive with a useful claw, paw, or hand, which can’t open but can still close and thus is able to grip and feel a branch, a piece of food, or a tool.

We reached the camp on the lake just before noon. Our Indian crew had cut some trees to make a clearing and used the wood to build shelters, tables, benches, and posts to which to leash the caimans. The pile we had collected the previous night was still in the bottom of the boat. They had been watered while we were at the village and didn’t seem to mind the delay. Even now, they seemed in no great hurry to get out. I stepped over them onto firm ground and then into a dry tent.

The camp was a research station for a number of different projects. The primary objective was to study the social behavior of crocodiles. Every night, we caught them in the lake and brought them to camp, where we did all those things Antonio found so perplexing. After a while we would begin to catch the same animals over and over, giving us an idea of the total population and whether they lived individually, in pairs, or in groups, and whether or not they were territorial. Meanwhile, entomologists were climbing trees to gain access to termite nests, to study not the termites but the termitophiles, tiny insects that live within termite colonies; botanists were dragging the lake with sieves to trap plankton; and biologists were doing research on plants, butterflies, snakes, and any serendipitous discoveries that might catch a biologist’s fancy.

My plan was to involve myself in each of the projects by being an eager assistant. My priority, of course, would always be to provide medical care whenever necessary, but if everyone stayed fairly healthy,
I knew I could learn a lot about the jungle. And if not, I would learn a lot about jungle diseases.

Our camp was a pinhole in a continent-wide entanglement of plants and animals that wove themselves into a tight green fabric covering half of South America. Of the thousands of hidden lakes in this rain forest, we had set up on the shore of this one, called Zancudo Cocha, because we had heard it was infested with crocodiles. I didn’t learn until after I arrived that in the local dialect
Zancudo Cocha
means “Lake of the Malaria Mosquito”—a jungle menace far more deadly than crocodiles, and the single biggest reason, among many big reasons, why so few people live in the Amazon.

Malaria has killed hundreds of millions of people worldwide over the course of history. Ancient Romans believed the god Febris inflicted it, and the remnant of that idea survives to this day as the word
fever.
Italians gave it its name when they noted that it seemed to come from the bad air, or
mal aria,
around swamps. The cause of the disease is actually a denizen of the swamp, the anopheles mosquito. After mating, a pregnant female gets hungry for protein to make her eggs. She seeks out warm-blooded, protein-rich targets by sensing the skin odors of animals and humans as well as by honing in on the carbon dioxide in their exhaled air. After landing, she makes test holes with her needle-sharp nose until she hits a blood vessel. Then she literally spits in the wound, injecting saliva, which increases blood flow by widening the vessel and preventing clot formation. The female anopheles has a distinctive style of blood-sucking, lifting her tail high in the air for the two to three minutes it takes to fill her tank. She won’t need a refill unless she gets pregnant again, and until then she’ll go back to feeding on plants—a much safer way for her to eat, since she runs no risk of getting swatted.

The mosquito wreaks havoc not because of the blood she sucks (only about one drop) but because of the dirty needle she uses to withdraw it. The mosquito’s nose acts as a conduit for parasites that flow into the bloodstream along with her saliva. They find a home in the animal or human liver, where they thrive and multiply for the next couple of weeks or months, the incubation period, before breaking
out into the bloodstream in full force to ride in red blood cells and destroy them, causing fever and chills. The debris flows into various organs, clogging them up and sometimes causing fatal damage. Even when a malaria victim survives an outbreak, a nest of parasites always remains in the liver. Untreated victims can look forward to periodic outbreaks of the disease for their entire lives.

The appropriateness of the lake’s name was immediately obvious. Of the uncountable number of insects that bit me during my time in the Amazon, however, never did I see a single one lift its tail in the air. In any case, we were all taking chloroquine, a synthetic pill that protects against most forms of malaria. There is no truly effective protection against the bites, however. Bugs in the Amazon are tough, and they laughed at our lotion or spray repellent. Some of them, judging from their reactions, seemed to need it to live.

Despite the bugs, camp life was pretty comfortable. Every night a team of crocodile catchers roamed the lake. I got used to having breakfast each morning alongside a fresh batch of black caimans leashed to poles, waiting to be weighed, measured, and tagged before being dropped back where they came from. Besides catching them, Antonio proved indispensable to the recording procedure, as I saw one morning when our researchers weren’t sure whether one of the crocodiles was male or female. Antonio did a rectal exam on the protesting animal.
Macho,
he announced.

Antonio was indispensable in other ways as well. Along with being the leader of our crew, he was highly respected among the Cofan Indians as a repository of rain forest knowledge. Since his primary involvement was in nighttime crocodile patrols, he was often free during the day, as was I, when no one needed my attention and I wasn’t assisting one of the biologists. He had never thanked me for sewing up his grandson, but he seemed to pay me special attention.

Except for the usual jungle complaints—dehydration, diarrhea, itching, and fungus, our team remained pretty healthy. Word of my surgery on Hermanigildo had spread, however, and before long I was receiving office visits from villagers arriving via back trails or pulling up in canoes. One boat approached bearing two girls and a little boy in the front and a woman paddling in the back while holding a baby
on her shoulder. She guided the dugout canoe onto the shore as smoothly as if she were parking the family car. Everyone got out, leaving a rifle and a baby bottle on the seat. My patient was the little boy. His mother had brought him because for weeks he had been crying, not eating, and having diarrhea. Sebastian asked a few questions for me, and I noticed that whenever the mother hesitated, the older sister jumped in and answered. Like Hermanigildo’s sister, she seemed to be in charge of the baby; it was apparently just one of the many tasks routinely delegated to young girls. My examining table consisted of a row of heliconia leaves (large flat ovals, each 2 feet long) laid side by side right on the ground, which since it had been cleared was getting muddier after each rain. The boy looked uncomfortable; his stomach was a little bloated and his liver felt enlarged. He might have dysentery or, worse, he might have schisto—yet another reason the jungle is an extreme environment.