On the morning of our first adventure I woke up as ready as I could have been. Everything had been meticulously packed and I had quadruple checked my lists. The rubber boots I had dug up from the bunky the night before were probably two sizes too big, but they were the only pair I could find big enough for my moronic feet. So as I marched up towards the dock in my clanking clown galoshes, I knew I was in for a rough one either way. I was surprised, actually shocked, at the amount of bags we were bringing, everything happened so quickly that morning I didn’t get the chance to take a photo, but the boat was so full we almost had no room for us. With all the fortified rice, reading glasses, soap, and food we were preparing to give away to the communities, our haul was truly menacing. While the boat skipped ever gracefully across the water, I tried to take in an appreciation for what I was about to do – act as the lead medical practitioner for the first time in my career, in a health system I didn’t know, with a population I had never met, in a country whose customs I don’t really understand. Not bad for a final year elective!

Our plan was laid out as follows, we were going to hit two communities over two days, spending a night. The first community, la Sabana, was one of the most isolated communities in the rotation, not an island but in-land, resting on a plateau high up in the mountains. It is only accessible during the day by hiking a mountain pass of roughly three hours, that passes through another village at the base by the name of Pueblo Nuevo, our second community. By virtue of being so isolated, La Sabana’s inhabitants (roughly 1000) didn’t have as much of the readily accessible vices that drive much of the chronic disease we usually see. There is not so much refined sugar, and the presence of alcohol is virtually non-existent. Ergo, this meant not as many diabetics, hypertensive or COPDers requiring regular follow up. Dr LaBrot told me that when his team got there for the first time ten years ago, it was the first time many of the elderly (in their sixties and seventees) had ever seen a doctor. For many of them it was their first time seeing the white man in a generation, and there was probably a single cup sugar in the entire village used sparingly for coffee. The idea was to reach Pueblo Nuevo, by first boating onto mainland and driving an hour up to the base of the mountain, leave much of our medicines and gear there on that Tuesday morning, and immediately ascend the mountain for La Sabana for an afternoon clinic. After spending the night, we would hike back down in time for a lunchtime clinic in Pueblo Nuevo and give out birth control injections that were meeting us there that same day. Simple right? Always is.

Arriving on the mainland we were met by our driver, who shares a name with Greek mathematician, and was full of banter all the way to Pueblo Nuevo. Arriving at the entry point of the community, we unloaded our belongings in-front of a long bridge crossing the river. This was the first in a series of three bridges, a stretch of probably a kilometer plus, that brought access from the main roads into the village. As we unloaded our gear, I stood over the pile while we waited for the wheelbarrows to arrive at the access point, and I felt an odd itch on my left leg. I looked down to find ants, the hot and hungry jungle variety, crawling literally ALL over my left boot. After ripping it off and flailing like an idiot in silence trying not to make a scene, Chrys and Jack helped us move some of the bags out of the grass. ‘That’s weird’ Chrys said, ‘I have never seen the ants act like that, you must have stepped right on top of them, what luck!’.

That should have been my omen.

Myself, Chrys, and Jack spent a solid hour and a half shuttling our gear over the three bridges and into the heart of the village. In that period I probably tripled the mileage I had ever spent using a wheelbarrow in my life. My back was sore and the heat made the metal handles hot to touch, that felt like my hands were searing. I was caked in sweat and exhausted before we had really even started.

A quick search revealed that the horses, which were meant to haul our gear up the mountain, where nowhere to be found. You see since there is no phone communication possible to la Sabana (allegedly there is one rock on the outskirts of the village that can be used by those with a phone to receive messages once a day), our alerts to them, mainly went out through radio and word of mouth passed on one village to the next. Some confusion meant our horses were not there, so instead of waiting around we decided to set up shop for our first clinic – my very first as the man in charge, a fair bit sooner than I expected. I changed out of my sweaty garments and donned my polo shirt and dressy shorts, it was time for business.

Needless to say things started just about how I was expecting them to. I was flustered, completely out of my depth, and doing my best to show some mettle. Not only that, but most of these clinics usually had up to five, six doctors usually, instead of one. The sheer number of people in the rancho, my general inexperience and the asphyxiating weight of feeling that there’s no way you will get to see everyone in time was enough to make me tremble. The very first patient I saw, a diabetic with high blood pressure who was getting a renewed prescription and regular follow-up, got literally nothing from me. Our blood pressure cuff was broken, I couldn’t get the pump to re-inflate after I squeezed it, and our glucometers for some reason were displaying different errors on all three. I made the best of it that I could, asked how things had been going, if she had any complaints, with a clinical exam and brief chat. The real purpose of our visit, which was to see if any of our chronic patients needed readjustment of their metformin or amlodipine doses, was basically null. I put my nose down and just got on with it, and I think at the time I didn’t recognize how truly overwhelmed I felt. I felt sorry for the patients, and I felt sorry for the team. Neither my teammates nor the patients felt sorry at all though. They didn’t voice any concerns, didn’t ask me how I was doing, or if I needed help. Carrying on as usual, they saw me at work and what they saw was a doctor. They believed in me and that made me believe in myself. That was enough to get me through.

One of the things that I found interesting as the clinic went on was how similar it felt to any other clinic. You had all types of patients on the spectrum: the ones that were happy to be there, full of chatter ‘of course doctor I am happy to wait, you please take your time’, the ones that were strangely timid and wouldn’t look you in the eye, seeming embarrassed to be there, the ones that were downright rude, not given you anything that made you feel like you had somehow wronged them as they waited for an apology. I’m not sure why I was expecting any different, I suppose people are just people no matter where or how you find them. One woman brought in her daughter, a seven year old girl with a daily spiking mild fever, and a bit of anorexia (lack of hunger). I started with the basics, took her pulse and temperature, listened to her heart. In those moments where I felt like I was a walking imposter, the routine clinical exam was the thing that saved me, that basic ritual I had done a thousand times over. With children there are a few things you always check, the ears, the mouth, and the urine. At least that’s what I was taught by one of my GP mentors. I started with the ears, grabbed the otoscope and could see nothing – and I mean literally I saw black, because the otoscope was broken. Goodie. I moved on to the throat, got her to open wide, and caked on her tongue I saw deposits of what looked like cottage cheese, also around her molars, sparing the back of her throat. Yikes, I thought to myself. I asked for a minute and called the boss. Oral candida, the fungal infection that I had learned to be a telltale sign of immunosuppression and HIV, was pulsing between my ears. Dr LaBrot helped me through it, ‘how does she look?’ he asked. This fundamental question forming such a monumental part of the GP repertoire was always my guiding light, and I was learning it as we spoke. ‘She looks fine to be honest, giggling and running around with her siblings as a talk to you, no fever at the moment’. Oral candida it turns out, is common enough in young children with poor oral hygiene. Normally we carried nystatin, the swish and swallow antifungal, but not this time as we came up with the bare bones for these modified Covid era clinics. I wrote out instructions on what to do with nystatin and where she might get it at the nearest town with a pharmacy, and gave them a toothbrush with some soap and a bag of food. On to the next one.

I had one patient later in the day, a lady in her seventees, lovely woman who was very friendly. She was collecting her prescription for metformin. She had a history of insomnia over the last few months, waking up early and couldn’t go back to sleep. Her history revealed nothing to really latch onto, and as I resumed my ritual of taking vitals we were chatting away while I took her BP. (Halfway through the clinic after I settled myself down I figured out how to finesse the BP cuff to make it sing, it just required some well-timed slaps of the pump to re-inflate as you went). I watched the needle crest up nice and high as I usually do, up into the 180s, before I start the release and listen closely. At 175 I heard a thump of her heart, and then another. It crested down to 110 before it went away. That can’t be right I thought, and tried again. ‘Let me see the other arm’ I said. Same reading. This woman’s blood pressure was sky high, and I had no idea what to do.

Again I called the boss. I explained it to him. I tried the cuff on both arms, upside down sideways and every way in between, what do I do? He said ‘Well, this woman has hypertension, lets put her on an anti-hypertensive’. I started her on 5mg of Amlodopine and gave her big long chat. I talked to her about blood in veins, about pressure and about pipes. I think she understood. She was happy to take the meds and off she went. ‘Well done’ the boss said ‘That’s your first diagnosis of hypertension, first future heart attack, stroke, or loss of vision averted. Good job’. It was so insanely simple and yet so much of my training had taught me that it never could be.

The thing about this type of medicine is that it forces you to peel away all of the nuances that you are taught in medical school. In the entire time I spent in the field over the next two days, in the vast majority of my consults, the things that saved my skin time and time again I never read once in a textbook. The amount of mothers that came to me (of which probably every woman in the community under the age of 45 was pregnant or breastfeeding) with children that had nonspecific symptoms and no clear findings was immeasurable, and my million dollar question always remained ‘How do YOU see them? Are they well?’ Time and time again it got me out of trouble when I had no real answer. ‘If they can cry and fight that’s when I’m not worried. I get worried when they just flop around like a dead fish’ were the words of one of my GP mentors in Wexford, and how her lessons now held true. I almost had to do away all the fancy measures we use to diagnose the screamingly simple. Blood pressure is 160/110? You have hypertension, here is your amlodipine right here and now. What else are you going to do, make them get at 24 hour BP monitor? Where? How? Forget it. Blood sugar is 400? This patient now has diabetes, they are now on metformin, and you can hold the renal function test and trade it for a urine dipstick, unless you think that they can get renal function or 24 hour creatinine tests out here where they hardly have running water. Shortness of breath and bilateral wheeze on exam? Blow into my peak flow tube good sir, you have Asthma. Pain in your hands and ulnar deviation of the fingers is rheumatoid arthritis. History and exam is enough to diagnose, as a matter of fact it’s quite literally all you have. I felt like I was able to do actual things, and it was an amazing feeling. I didn’t stop for lunch. We kept going as the patients kept coming. Started at 11 and the horses were coming down for us at three, and I was happy to take it to the final bell. Even though all day I saw probably close to thirty patients, the vast majority of which got nothing new, or some simple paracetamol to ease their headaches, or ibuprofen for their back pain, I felt like I was helping. Then things got a bit fucked.

We were almost fully packed up, right after 230. Jack and Chrys were off somewhere with the gear and I was taking the blood pressure on the last patient in the Rancho, when Jack our clinic manager came running up the path. I could tell he was flustered because he was screaming at me in English. He had never spoken to me in English before.

‘A horse Juan… He hit… A horse hit a boy!’ he shouted as he rounded the fence

‘A horse?’ I asked. I still had one ear in the stethoscope tethered to this woman’s arm.

‘A horse fell on a boy he is on the ground we need a doctor! I ran here.’ He was panting

‘Okay’ I said. I guess that’s me.

Just like that I picked up my stethoscope, grabbed the orange emergency bag and ran after him.