This following week would provide a much appreciated break from the madness of overnight clinics. We were staying locally, hitting three communities within thirty minutes of our base. This was nice for two reasons. Number one: I’d get to sleep in my own bed for the whole week instead of tossing and turning like a tortured worm inside a damp hammock. Number two: these communities were close enough that most of the people in them had fairly easy means to access healthcare at the hospital in Bocas town, which meant less volume, and actual day clinics that were true to their name and didn’t end with me doing exams in the blinding company of Mr Headlamp. Our first clinic was in a place called SharkHole.
The usual suspects voyaged out in clear skies and arrived at the long wooden dock that guided us through marsh where ducks noisily cleaned their feathers. The rancho itself was fairly standard as far as ranchos go.
After six clinics, and six weeks on the job as a doctor, I no longer felt a lot of the uncertainty that comes with being new. In essence, I had already endured the first month jitters of residency, just half a year sooner than my colleagues, and in conditions that perhaps it’s fair to say are slightly more colourful. I knew that I truly earned the title of physician (unofficially) when I experienced something for the first time in that clinic: I was beginning to get annoyed by some of my patients.
Honestly, dear reader, I swear I do my best. Even with the Ngäbe, as they so often do, look at you with silent eyes after you ask very clear questions that you know they understand, I keep it all under the hood. I understand they are a different people, and I understand that their medical understanding is not always sophisticated, but god damn sometimes I wish they’d throw me a freaking bone. One of my personal favourites: a twenty three year old man who works daily on a farm and looks fit as a fiddle.
‘What can I help you with good sir’
‘I have pain’
‘Okay. Where does it hurt’
‘Everywhere’
‘Right, okay. When you say everywhere, you mean like in your arms and legs?’
‘No like everywhere’
‘And when you say everywhere what do you mean. Where does it hurt? Where is the pain? Your back? Your chest?’
‘Everywhere’
‘Okay, right. So how about your stomach. Does your stomach hurt?
‘No’
‘How about your head?
‘No’
‘So where is the pain’
‘Everywhere’
‘Right… Okay so moving on. So how long has this been going on for?’
‘For a long time’
‘When you say a long time do you mean like, three weeks, three months, or like fifteen years?’
‘A few months’
‘How many months?’
‘A few’
‘Like two months or six months. If you had to give me a number’
‘A few months’
‘Okay, right… So let me get this straight. I’m not being pedantic, I just have to know with precision what is going on here so I can figure out what we can do to help. You have pain everywhere, for the last two to four months? Correct?’
‘Yes’
‘And when do you get this pain?’
‘All the time’
‘Of course… So how about right now, do you have the pain?’
‘No I don’t have it right now’
‘Right okay, so when do you get this pain then? When you’re walking? In the morning? When you work on the fields? When do you get this pain? This pain that occurs literally everywhere, but not your stomach or your head, but everywhere?’
‘All the time’
‘Gotcha’
His prescription was to drink more water.
The difficulty can be that as much as patients can sometimes be insanely difficult, they can also sometimes have something really going on with them medically. It can be hard enough to wade through miscommunication, and doing that while dealing with your own frustrations of banging your head against the wall makes history taking an art of mindfulness more than a science sometimes. I saw a lady during the week who was a tremendously difficult historian, we took one step forward and two steps back. She had back pain for twelve years, which had gotten worse over a month ago and not gone away. That much information alone took me almost five minutes. A very general back exam showed that she had shooting pains into her legs when she laid flat and I raised her leg, (a test astutely named the straight leg raise). This was grounds for some serious workup, a CT scan and potential surgery. I walked away from that consult nearly cursing myself for feeling so frustrated with her initially. I can only imagine what this can be like when you are near the end of a twenty four hour call, after having worked for 11 days straight, with a husband or wife at home who needs love and affection too. I was starting to see how some people can overlook things that might seem obvious. After all, would be very easy to look at a sheet of paper that says ‘back pain for five weeks’ and think to yourself how silly of this doctor to not do a straight leg raise. I always make sure to write ‘difficult historian’ on there to cover my ass. Somebody needs to know that I laboured intensely for those words. Anytime I pick up a chart with a patient age below 30 with ‘pain’ I am always a bit doubtful. There was one gentleman in Sharkhole who was twenty three, with significant pain in his left leg. I began with my usual skepticism
He walked with a slight limp and wore two massive galoshes up to his knees, with coarse denim pants on a day where the sun was bonafide roasting – that should have been a hint. He began to tell me about this pain in his left leg.
‘It hurts when I walk, but also when I am sitting still, although it’s not as bad’
‘Okay how long has this been going on for?’
‘Four months’
‘What does it feel like?’
‘It’s a crampy pain’
I asked all my classic pain questions, and nothing seemed to catch. Then I asked him if anything had happened four months ago.
‘A snake’ he said.
‘A snake?’ I answered, as if I didn’t believe what I was hearing.
‘A snake’ he said.
‘Let me take a look…’
Snakebites are a big problem. Anywhere where it’s hot year round, which is something we can’t really appreciate in most of the world’s temperate climates, they remain a source of impairment and disease of significant proportions, having been declared a neglected tropical disease by the WHO in 2017. Global estimates are difficult to gauge, since most of the people bitten and most afflicted live in areas where medical record keeping is not a huge priority. Current estimates put the number of bites at around 5.4 million per year, with around 2.7 million envenomations. Every year 400 000 people lose their limbs, and around 100 000 die. This is for several reasons.
Firstly, most venomous snakes have venoms that are fast acting, and broadly they are lumped into two classes: Elapidea and Viperidae. Elapidea snakes have fangs that don’t retract, like the mamba or the cobra, meaning they are always pointed outwards in their mouth. They commonly secrete neurotoxic venoms that act on the central nervous system, causing arrhythmias of the heart or widespread paralysis of respiratory muscles. Viperidae, or Vipers, have retractable fangs, and commonly attack their pray with cytotoxic enzymes that degrade cellular proteins. This means that a viper won’t make your heart stop, but instead turn your leg into dead tissue until it rots off completely or the resulting infection kills the host anyways. These two classes of venoms make the treatment strategies different depending on what kind of snake bites you, which is why it’s actually hugely important to ask people to describe what it looked like or the sound it made when they come into a hospital after being bitten.
The solution on paper of course is anti-venom—which is commonly synthesized by injecting animals, horses in particular because they are highly immune to many venomous snakes, and then extracting antibodies to the venom made in their blood. It’s a very expensive process that requires sophisticated labs, livestock, and venom from the specific snakes that live in every region you are trying to treat with that serum—presumably at some medical facility that keeps its stock up to date with local species. However, once the venom has taken effect any use of anti-venom is completely moot, because the damage is already done and the venom is now exhausted, meaning that in the acute phase you have to get them to hospital immediately. Of course this isn’t always possible, so you have to just do the best you can. For neurotoxic bites, you want to support the central nervous system, which means respiratory support or cardiac monitoring until it wears off, and try to keep the toxin localised to the limbs far from the heart. The opposite is true for cytotoxins, if you slap them with a tourniquet you are just maximising the local necrosis and guaranteeing awful destruction of their cells. Trying to suck the toxin out or cut the skin has been demonstrated empirically to not work at all, and at worst produce a lovely entry point for more infective agents into the body. The nature in which the bite occurs is also relevant, for example, many rattle snakes may bite several times with producing any venom, so called dry bites; this is if they encounter something only slightly annoying. If they approach someone that the mistake for a rodent or potential prey, they might inject a small amount of venom that they think is just enough to kill, because venom is tremendously expensive to produce. What you don’t ever want to do is step on a snake, or make them feel threatened, because pushing them into fight or flight produces a defensive bite, where they will empty the entirety of their poison because they fear for their survival. Cue the galoshes.
His leg looked like it had been grilled on the barbeque, then eaten, and spit back out after the taste was too offensive. All the way from his medial malleolus (the inside bone of his ankle) to right around his knee was thick scar tissue. Halfway up his shin there was a cherry red lesion the size of a coin, the location of the bite. He had been absolutely decimated. This was despite his one month in hospital after the bite, and two skin grafts harvested from his thighs to replace the necrotic tissue. In Panama the Fer-de-lance—Pit Viper, which gets its name from the French translation meaning iron-tipped lance—is the usual suspect to produce cytotoxic bites of this nature. While not being the most venomous of the region, its aggression and high numbers make it the most problematic. This is especially true in the fields where many of the Ngäbe work, which if left unkempt for two long can produce long grass that masks their movement completely. All the damage had been done here, and a thorough examination revealed the extent of that damage. Muscle weakness and sensation loss on the afflicted leg was his cross to bear. He was also very sore on contact to the skin, likely due to nerve destruction. Our friend here was not going to work the fields anytime soon, and likely would suffer from permanent disability for the rest of his life. No wonder the devil took the form of a snake. Really glad St. Patrick drove them all out of Ireland. Go on you boys in green
The following day’s clinic at Cerro Brujo didn’t provide any slithering surprises, but it did represent a great Floating Doctors achievement. Kelly and Iraida gave a series of women’s health talks to the community, and distributed over thirty packages of re-usable feminine hygiene products donated to us by the non-profit Days for Girls. It was the culmination of a two year project instigated by Kelly herself. I kept looking for patients that were charted but nowhere to be found, because their talks attracted more and more women from the community as the day went on. It was an incredible thing to see, especially considering the sheer volume of obstetrics and gynecology that formed the bulk of my sick patients. Ironically enough, we were late getting out because my last patient needed treatment for a sexually transmitted disease, that both her and her husband were likely carrying, although he probably didn’t know it. I was sharing stories about my time here with some friends in Ireland, a husband and wife. The wife told me how not surprising any of this was to her.
‘It sucks enough being a woman as it is. I can’t even imagine what it’s like for them there.’ She said. She was dead on, and I don’t mean this in any kind of feminist sense. The Ngäbe women that I treat almost always dedicating themselves to housework, which is something that makes total sense to me. Someone has to be at home to cook and clean after the seven children while Dad is out swinging a machete in the sun from sunrise until dusk. It was a division of labour that was completely necessary to their survival.
However, regardless of where you stand on the feminist movement, at least from the biological perspective, we can all admit that the females among us got the short end of the stick. Pregnancy, hormones, bloating, urinary tract infections, even depression is more common in Women. Don’t even get me started on high heels, I tried a pair of those bad boys on once and they gave me calf cramps immediately. Ever since Eve came out of Adam, women got the shaft, there is no denying it. I wonder if Eve menstruated in the Garden of Eden… I imagine paradise was probably period pain and bloating free. It’s a shame she took a bite out of that apple.
If it wasn’t for that bastard snake.
