Surviving the Extremes: A Doctor's Journey to the Limits of Human Endurance (5 page)

Antonio had decided this without even consulting the doctoro. I could have been insulted, but that would have been silly. This was the jungle, and here Antonio was in charge.

Before the boy appeared, we had been on our way to our lake encampment. The village was located on the river. We changed direction, heading toward the mouth of the lake. Antonio and Berullio conversed about something, told little jokes, and in general showed no signs of urgency. This was one more trial of the jungle. The tough would survive, the weak would not. We paddled on at a pace no faster than before.

Exiting the lake, our canoe entered a current of muddy water. We paddled upriver around submerged logs and twisted branches to a wide mud beach. Above the beach, a bank of mud sloped upward to a clearing in which I could just make out the tops of two huts. Other canoes from our expedition had already arrived and were taking on some supplies, getting ready to set off for our research camp on the lake. A dozen kids ran up and down the beach, enjoying all the excitement.

I stepped out of the canoe into soft mud and sank to my ankle. I made a second step and went in up to my boot top. The thought of the third step was too much even for the Indians watching from the shore. They signaled me to wait, then hauled a canoe across the beach and pushed one end toward me. I stepped into the canoe, walked the
length of it, and then stepped out onto firmer gray mud. The doctoro had made his entrance.

My patient was already waiting. He came directly up to me on the beach and silently held his left arm up for me to examine. He looked to be about nine, meaning he was probably seven. Kids mature fast in the Amazon. I didn’t know any words in Cofan, the local language, and he didn’t speak anything else, but an easy smile and a confident manner don’t require translation. Still, I couldn’t tell if we were communicating. His eyes were open wide yet too dark to read, and his face remained expressionless. I took his wounded hand in both of mine.

The wrist was caked in mud and dried blood, the hand drooping forward. I wanted to get a look at the cut, but I knew that once I removed the mud it would start bleeding again. As we stood there, surrounded by a crowd of adults and children of all ages, I spotted what looked like a clean rag in the sand and walked over to pick it up. All eyes followed my every step. The audience was far more intrigued by the Western doctor than by the injury he was treating. Cuts, they’ve seen before. I started wiping the wound. The boy watched carefully, still without expression, even when the plug of mud fell away in one lump and a pulse of blood spurted out. By the second pulse I could see that the cut was very deep, running straight into the wrist from the thumb side. I used the rag for compression, placing it where the mud had been. From the liveliness of the bleeding and the dropped position of the wrist and thumb, I knew an artery and some tendons were cut. It was likely that the nerve running between them had been cut as well.

“How did he do this?” I asked Sebastian, our guide, who spoke Cofan, English, and Spanish and often needed all three to keep the group together.

“He was in his father’s canoe this morning, clearing a channel. The water level was low and the canoe was caught on some submerged grasses. He reached underneath, grabbed the stalks with his left hand, and chopped at them with the machete in his right hand. He missed.”

Though this wasn’t the kind of patient history I get too often in New York, the type of injury was certainly familiar. I had treated one
just like it only a few months before. A teenage boy cut into his right wrist in what I initially assumed was a suicide attempt. His psychiatrist pointed out that the boy was right-handed, however, and that had it been a suicide attempt, he would have used his right hand to slash his left wrist. In fact, the boy had been trying to cut off his right hand as punishment for masturbating. I spent hours and hours in an operating room, using a microscope to repair his hand so that he could masturbate again. That was the kind of incident that could only happen in a modern, highly developed country, someplace you couldn’t get to from here. Perhaps more than anything else up to now, the thought made me realize how far I had traveled.

“He is going to need a full-blown operation,” I told Sebastian, “but I think we can do it here. If not, he is going to permanently lose a lot of the use of his hand.”

“Of course,” Sebastian replied. “What do you need?”

We were still standing on the gray mud beach, and the morning sun was getting intense. I suggested we move up to the small clearing, where the footing was better and where we would have some shade. Sebastian spoke to Berullio, who found an empty oil drum, placed it near another one already there, then returned with a wooden plank, which he laid across them to give me a narrow table. The drums were stuck deep into the mud and the plank was stable, but it was only about 2 feet off the ground.

The boy sat straddling the plank, leaned forward, and extended his arm onto it, but it was too low for me to work on. Bill Jahoda, the college professor and our expedition leader, saw the problem right away. He volunteered to sit on the other side of the plank to support the boy’s arm on his legs. That raised the wrist another foot off the ground. We were at the edge of the clearing where the slope was still steep enough so that if I sat on my knees in the mud in front of the table I was at about the right height. It wasn’t my three-way tilt chair with padded armrests that I was used to at my hospital, but the arrangement suited me perfectly.

By now, a crowd of about thirty people (more than the entire population of the village) had collected around us. Sebastian attempted to disperse them by announcing that our crew was down on the beach
giving out oranges. The adults left, but the little kids all remained to watch. They didn’t care what Sebastian said.

I kept my surgical instruments and most of my supplies in a large fishing tackle box wrapped in a waterproof plastic bag in one of the canoes. A crewman went down to get it while another took two pails to fill with rainwater from an open drum behind one of the huts. They spread out the plastic bag on the mud and placed the box and the two pails on it as if they were setting up for a picnic. I opened up my medical kit and laid out my instruments and supplies in the order I expected to use them—gauze pads, retractors, hemostat clamps, cautery, scalpel, forceps, scissors, needle holder. This is a job usually done by my scrub nurse, so I paused to visualize every contingency and make sure I had everything I needed. My immediate environment, at least, was becoming familiar. I was in the OR now. Up to my knees in mud.

I put on sterile gloves and used a Betadine scrub to paint the arm and hand, as well as part of Bill’s hand and quite a bit of his pants, as he was unflinchingly holding the arm across his legs. Then I laid a sterile drape under the boy’s hand and across Bill’s lap, tucking it into his pants so it wouldn’t slide off.

Sensation to the hand and forearm is supplied by three major nerves, two of which ran into the territory of the injury. To provide anesthesia, I would have to block both, using lidocaine (the same medicine a dentist uses to numb teeth). The injections were exactly what I would be giving in a regular operating room, but here they almost seemed unnecessary. An injury of this magnitude should cause intense pain, yet the boy made no complaint. In fact, I hadn’t heard him utter a word since I met him. He was calmer than I was.

All doctors have seen examples of patients with major injuries who feel no pain. Pain is an alarm that alerts the conscious mind to bodily injury, motivating it to do something to correct the condition. When the damage is massive the problem is obvious; no alarm is necessary. A flood of pain impulses proportionate to the injury would serve no purpose, and in fact would interfere with the signals the brain is trying to generate to coordinate an effective response. The more desperate the situation, the more critical it is that the pain signals be squelched.
It is a universal survival mechanism, one activated more frequently and more forcefully as environments become more extreme.

As I drew up the lidocaine into a syringe, I told Sebastian to tell the boy that this would hurt but that he would feel no pain afterward. The words seemed to me a rote formality. This boy was the most stoic patient I had ever seen. Berullio squatted behind the boy and held his shoulder. When the needle went in, the boy screamed and started to cry. I was startled. The machete wound had engendered only carefully calculated, purposeful responses, yet a simple needle stick nearly brought on hysteria. I shouldn’t have been surprised. The reaction made sense from a survival viewpoint. The situation was under control. The boy could now afford the luxury of feeling pain again, and this was just the sort of injury for which an alarm is needed. The sensation is equivalent to being stuck by a thorn, a spine, or a splinter—the kind of trauma that if ignored might lead to sustained bleeding, poisoning, or overwhelming infection. Crying would not have been useful while he was in survival mode, but now the boy was in a protective environment. He was surrounded by people who could offer him aid and solace if he made it known that he needed it. I was reminded of my daughter. One day while playing at home, she fell over a chair. I was home, but my wife was not. My daughter got up without a peep and continued her game. A moment later my wife came home, and my daughter ran to her, screaming in pain. Subconsciously she had judged that reacting for me wouldn’t be worth much but that reacting for mommy would bring a much greater reward.

It was taking a few minutes for the nerve block to work. I had given the injection in the forearm, “upstream” of the injury, and the lidocaine was slowly flowing down the nerves into the hand. While we waited, Berullio comforted the boy, wiping his tears and helping him blow his nose. With a start I realized that this was Berullio’s son, a fact that had been common knowledge to everyone but me. His name was Hermanigildo. Antonio was his grandfather. I had been so tightly focused that I had been oblivious to any social nuances around me. The father-son interaction that I was seeing now was what you would expect in any culture, but it made more intriguing the behavior I’d witnessed in the canoe that morning. Berullio was proving every
bit the supportive parent, but earlier he and Antonio had shown no agitation or special concern for their son and grandson when he was alone and out of reach. Perhaps this was because they knew that sympathy at that time wouldn’t have helped and might even have been counterproductive.

I asked Hermanigildo if he could feel me touching his fingertips, and he shook his head no, so I began to work. Bill held the arm up a minute to drain out as much blood as possible before I wrapped a tourniquet around it, a low-tech but highly effective technique used in even the most modern hospitals to stop blood flow completely. Without it, doing hand surgery would be like trying to fix a watch in the bottom of an inkwell.

Only now did I remove the rag I had inserted against the boy’s torn artery on the beach. I washed the inside of the wound using Betadine, peroxide, and rainwater. Once all the mud and jungle glop came out, I got my first good look at the damage. The cut ran a third of the way across the back of the forearm, just above the wrist and thumb. It was a neat cut; the machete must have been very sharp. I couldn’t see inside, since the edges were not gaping open, so I took a long wooden Q-tip, jammed the hub of a needle over the cotton ball at the end, then bent the tip of the needle into a hook. Two of these devices made excellent retractors. I stuck one in each side of the wound, pulled them apart, and gave the ends of the sticks to Bill—who was now both my scrub nurse and my OR table.

Using a forceps and scissors, I probed the wound but still couldn’t see to the bottom. The cut was too deep, and while the small clearing we were in provided shelter from the blazing sun, it made for a dim operating room. The trees rose up to form a densely intertwined canopy high above, preventing the sunlight and the wind from reaching the ground. Light filtered down only in thin shafts that came and went with the movement of the leaves. Kneeling in the mud, in the soft light and still air under the vaulted ceiling, I felt the setting was more appropriate for an outdoor cathedral than an operating room.

“I need a flashlight,” I said to no one in particular. Two of our team ran down to the canoes and came back with two powerful lights. “Try to position the beams on either side of my head and hit the skin
surface perpendicularly,” I said, without taking my eyes off the wound. They directed them perfectly. The bottom of the wound was illuminated, and with some more probing I found four cut tendons and one cut nerve. There were also cuts through the radial artery and several veins, as well as a gouge in the radius bone where the force of the blow had finally been dissipated. A machete is a fearsome instrument, especially when you consider that the swing had been blunted by the resistance of water.

I estimated how long it would take to repair all the injuries. “Can you hold steady for two hours?” I asked my human light holders and my table supporter. All three said not to worry. They were fine.

Two hours might not be enough time to repair everything, but it would be about as much time as I could hope for. I knew my three assistants would last as long as I needed them. The tourniquet was the limiting factor. There would be no blood flow to the arm during surgery and hence no fresh supply of oxygen. Limbs deprived of oxygen undergo permanent damage after about two hours, which is why applying a tourniquet can be so dangerous. After the first twenty minutes, however, the arm would become increasingly painful. With no anesthesiologist to provide heavy intravenous sedation, my operating time would depend on my patient’s pain tolerance.

Tendons are like ropes that connect muscles in the forearm to bones in the hand. When a muscle contracts, its tendon acts like a marionette string, moving the body part to which it is attached. Two of the tendons that were cut hold the wrist up; the other two hold up the thumb. Without them, the hand can’t be lifted and the thumb can’t be opened for grasping.