Polio is an RNA virus from the enterovirus family. It commonly enters the body through infected food or saliva, and colonises the GI tract. In a subset of infections, the virus passes through the walls of the gut into the bloodstream where it hijacks local cells and begins to reproduce. From there it can distribute itself throughout the tissues of the body, including the saliva glands and the central nervous system, where it can cause all sorts of trouble. In particular, its impact on the nervous system can lead to infections of the tissue surrounding the brain (meningitis), the brain itself (encephalitis), and the nerves that line muscular tissue throughout the body (neuromyelitis). Polio neuromyelitis is the form of Polio that makes up the visual imagery that people think of the when they hear the name. This comes most commonly in older children, where Poliomyelitis causes permanent disability in the growing limbs. This leads to physical malformation, as the limbs their function forever due to the damage.
All accounts suggest Polio has been around for a very long time dating back to the ancient Egypt, although in modern medicine it was described with great specificity in the 1800s. At the turn of the century around 1900 all the way up to 1960, it became a global epidemic across Europe, North and South America, and the English speaking colonies. My mother shared a story with me from her father in Argentina, where the disease spread from community to community by virtue of proximity. She tells me of how families would relocate several times a year, fleeing from the incoming wave of positive cases in nearby communities in crippling fear for their children. Year after year the disease followed, growing closer and closer until some people had no money to move or no good place left to go.
In the US during the nineteen fifties, it became the worst outbreak of disease in the country’s history, with over 20 000 people suffering permanent paralysis every year. Photographs of Polio treatment centres with dozens of dozens of iron lungs paint an impressive picture. The iron lung was used because of the impact Polio has on the muscles needed for breathing, like the diaphragm and ribs, which spurred many developments that form the basis of modern day ICU airway management.
Believe it or not, the concept of putting all the sickest people in the same place within a hospital was a novel concept in the fifties. In 1952, during the peak of the polio outbreak in Copenhagen, the Danish anaesthetist Bjorn Ibsen was dissatisfied with the Iron lung, as they were in short supply, cumbersome, and did no protect patients from aspiration of contents into the respiratory tract. Overwhelmed with patients, he changed the management. Instead of having patients scattered he put them all on the same ward, and opted for endo-tracheal intubation over the iron lung, enlisting 200 medical students to manually pump oxygen into patients throughout all hours of the day and night. To his great benefit, a Swedish physician and inventor developed the first mechanical ventilator around the same time, which went on to replace the many bug-eyed medical students. This innovation decreased mortality by upwards of 70%, and one year later Ibsen went on to found the first ever modern day ICU in a converted classroom within the hospital.
Hundreds of thousands of Polio survivors worldwide went onto to pioneer the fight for disability accessible infrastructure and improved vaccination. As a result of large scale vaccination programs, by the mid-eighties its incidence had been almost eradicated. At present, the disease on the verge of complete extinction, gone from every nation in the world except for two on either side of a war in Pakistan and Afghanistan. Even though this patient in front of me had been a chronic patient of ours for years, nobody knew the source of his paralysis until now, and it was only because I had Indio with me, who knew the case from his time working as the community nurse.
Entering the room, I saw him sitting on the floor in the centre, hunched over. It was a position that he spent most of his day in, between that an lying flat, because engaging the core muscles required to sit up was exhausting for him. His limbs hung at his side like dead weight, and his legs spilled out in either direction, one knee bent and the other leg extended to keep him upright. He heard us entering but didn’t look up, although he was happy to chat. We will say his name was Carlos.I introduced myself and asked him how he was doing. He tried at first to hide it, but quickly faltered.
‘Not good’ he said.
‘Okay’ I said ‘Tell me Carlos, why not good today?’
He began to describe a burning pain in his chest, and a pain in his back. It had been bothering him terribly for the last six months. I studied him closely as he spoke, the tips of his fingers moved slightly and he flexed his wrists a tiny bit while talking. His feet were both swollen, and almost looked compressed, with a bump in the middle. Despite his obvious disability, his speech wasn’t slurred, and cognitively he seemed all there, although he looked tired. He spent the whole consult looking down, because he didn’t have the strength to lift his head. I had a lot of questions about his condition but I saved them all for later.
‘I am just going to start with the basics’ I said to him, and began with his vital signs, blood pressure, blood sugars, and the standard intake numbers to document on my sheet. After more probing, I put his chest pain down to gastritis or gastric reflux. Then we moved on to the rest. His back pain was at the top of his back, right between his shoulder blades, indubitably a result of his posture, and I advised that he sit up using the wall as a back rest whenever possible. He had some family that helped look after him and moved him around a few times a day, so he agreed to let them know. He also had headaches, also surely due to his posture, I advised him the same and also recommended that he drink more water.
‘I don’t like to drink water’ he told me
‘You don’t like water?’ I asked ‘Why is that?’
‘When I drink water it makes me pee. Peeing for me – I don’t like it. I have to call someone over, they have to lift me up… and help me. I want to pee less.’ He said. It was something I hadn’t really considered, but it made total sense to me. It was an awful position to be in, and really made me feel for the guy.
‘How do you eat Carlos?’ I asked
‘I get someone to help me. I eat a lot of soups. Sometimes I might eat rice, but it makes my belly ache.’ At least with the soups he was getting some water as well.
We spoke for a bit about his diet, what kind of foods impacted his pains, and his general living. When I asked about his bowel motions I got a similar answer that I got for his urine. He went once every other day, and he was happy with that; any more would be a hassle. With his neuromuscular impairment, it was completely expected that he would get constipated—a lot of our digestion is facilitated by musculature in the abdomen that is engaged when standing up and walking, and this gentleman had none of that assistance. I gave him some stool softeners, part of his chronic medications that he agreed to use if he got blocked up for a period of two days or more. Having addressed his medical concerns I moved on to other things.
‘What do you do for fun Carlos?’ I asked
‘For fun?’ He said ‘I don’t do anything. Just sit here all day, sometimes out there facing the fields’
‘Surely you must have something that you enjoy! What do you enjoy?’
‘I read.’ He said ‘but it has been getting harder to read lately. My glasses, they are not good like they used to be. They are old.’
‘Certainly we can see about getting you some new ones’ I answered. ‘We will bring them up from the rancho when we head back. That is very important to me, that you have things that you enjoy and I will see to it. What do you read?’
‘I read the bible’ he said. A man of God. I suppose in his circumstances you kind of have to be.
‘Who is that man up there on the wall?’ I said gesturing to a portrait of him and two women. He was wearing a suit in the photograph.
‘Huh?’
‘This portrait on the wall. Carlos look at you in the suit! You look like James Bond!’
He laughed. This prompted a bit of chatter between us as I got him to help me with a neurological exam. He still had sensation in all his body, it was just his muscular function which was impaired. He closed his eyes and could tell me every place I was touching him, and when I asked him to move, he gave me a tiny flexion at the ankles and a slight bend of the fingers. I then felt around his belly for palpable fecal masses. His abdomen was certainly tense, but he told me at the moment he wasn’t constipated.
I explained everything we were going to do, the omeprazole for his reflux, some paracetamol for his headaches and back pain, as well as the stool softeners and vitamins. I asked to see his caretaker, who was in the other room, a niece. We spoke for a moment about Carlos and what we could do for him. Checking my watch I realised we were already late, and we had to wrap up. Saying my goodbye to Carlos, he was very thankful.
‘I hope to come back and see you doing better my friend.’ I said on my way out.
‘Yes yes, I do hope so. Thank you Juan. God bless you’
When I stepped out of his room, there were five or six new people waiting by the steps. They were all people who lived nearby and had caught word that I was at Carlos’ house. Another look at my watch and shockingly, I was now more late than before (funny how time only moves in one direction). Two of them just wanted blood pressure checks, which I was happy to do, although I couldn’t offer anything more and I apologized incisively. Another man had some pain, and was happy just to take Paracetamol tablets without much fuss. With that we sped off into the sun across the fields.
The rush made me clumsy, and after a few close calls, the inevitable happened. I miss-stepped by a fraction and my bargain-bin flip-flops failed me on the wet leg, plunging me knee deep into the delicious warm muck. My foot had been taken from me, swallowed up with no hesitation, and my leg actually couldn’t move. Cristobal and Indio, my trusted Sherpas meant to protect me, instead decided that the moment called for celebration, hooting and hollering with joy, taking pictures to forever document my idiocy. I had to abandon my footwear, which was cemented down in order to regain my foot. However, never being one to leave a soldier behind, I reached down into the mud and pulled him out by hand. The rest of the walk I was very careful, and on the lookout for snakes. At least if I got bit I had a mud brick to fight it off and the two Sherpas to laugh at me and take a photo of it.
When I got to the rancho things already looked like confusion and madness, as people were running back and forth packing up the bags and bringing things down to the boat. Seeing a half-man half-mud troglodyte carrying a flip-flop encased in carbonite probably didn’t garner much attention. I was quick to shout out to Jack that we needed glasses, to send them back up for Carlos, I had his prescription and everything written down.
‘The glasses are gone.’ He said ‘Already packed in the boat.’
Damnit Jack. I wanted to be really upset, but I still had a hundred things to do, pack up my things, give the last guy his paracetamol and confer with Nicole what we were doing for Carlos. It’s only now upon reflection that I really have time to be frustrated and mad that we couldn’t at the very least give him back the one thing he enjoys, which would have been so goddamn simple. I should have stopped everything and run down to the boat and dug out a pair, two pairs, anything for that matter. At the very least I made a note in our chronic patient list to bring him spectacles when we do our next medication drop-off in one month’s time.
Indio brought us another bag of fruit, and on our way back to the boat we popped back into the crafts hut and I got myself a little necklace. It’s made of seeds and has a wooden cross. I am not really one for Christian iconography but my parents are Catholic, and I wear it as a way to keep me connected with them.
On the boat heading back to base, I got to just sit and relax. I’d love to tell you that I thought about Carlos, or about my trip, but I didn’t. I just sat there under the sun and watched the water pass me by, letting my empty mind enjoy the sounds and smells of our amazing existence. Just like that, my final clinic in the books.
Ten weeks in the jungle: Signed, sealed, and delivered by a guy in a rush with two limbs caked in mud.
It was almost fitting wasn’t it?
