We began our ascent towards La Sabana at 7 in the morning. We had one pack horse with us, and our horse-man Oligio was to be our companion. He was like many of the natives, soft-spoken, but with kindness in his gaze, and sharp features holding up two big brown eyes. He had hired the boy from the day before, who spent the night in Changuinola hospital. He hardly knew him, and they had only met that morning.

I don’t consider myself a veteran hiker by any means, but I have done my share of hikes, and athletically I am no slouch. I was determined to show my stuff to my native companions and not be the source of delay. This was all going well and good until about 5 minutes into the trail, with my first step in the mud, when a whoosh of muck soaked the sock on my right foot. Unbeknownst to me, this boot, the only one from the bunkhouse in a size big enough for me, had a huge gash right up through the instep, right at the seam. The gash was so big that every step in the muck introduced more sediment, soil, and rocks into my situation. Also by the way, we’re not talking about walking through the park on the way to school mud. This was jungle mud after a night of rain, a thick adhesive soup that would gladly gobble up your legs like a frog would a buzzing fly. My sock was absolutely caked in it the whole three hours. By the time I pulled it out, it resembled something painted by Van Gogh. Every patch of mud further compromising me, I had to step carefully and awkwardly, leaving my left foot often exposed to unfair circumstances and burdens. Needless to say I arrived at La Sabana caked in mud and sweat. The weather held up for us at least, and it was hot but not scorching.

La Sabana was nestled on a plateau that formed a valley, with cliff-like mountain reaches on either side. They were really breathtaking and beautiful. The village construction was fairly humble even in comparison the Pueblo Nuevo, mainly plank wood houses with straw roofing. The village rancho had a sheet metal roof at least. All the women were pregnant, and wore traditional dresses with vibrant colours. The little girls in particular, were the cutest things I had ever seen with their flowing dresses and dimpled smiles. They had a small pasture with decent cattle at the entrance of the plateau, and banana trees planted on the outer rims of the village. There was also a river nearby with fresh mountain river water that was cold and crisp, making for a life altering bath. One of our own made a little video that encapsulates some of the beauty.

We immediately set up shop for our clinic in the rancho. I thought for certain we would have to bathe before we saw any patients, but Jack and Chrys wasted no time. I took a minute to change, donned my PPE and was ready to go within twenty minutes of taking off my bag.

La Sabana’s small size meant that in total our chronic patients that we were bringing prescriptions for was five, if that. And yet our clinic swelled up to nearly thirty within the first hour. I saw everything from diabetics topping up meds, a woman with intense unilateral conjunctivitis, three pregnant woman who wanted to know the sex of their baby (alas I had not even a Doppler ultrasound, and could only tell them if their child was a decent size for their dates based on surface exam of their uterus), and children, oh the children. This folks, is a pediatricians dream. Every woman has an average of probably six children, and between a handful of families I had nearly 30 kids in front of me all with different ailments. In particular, I saw nearly a dozen children with the same rash pictured below. The locals call it manchita blanca (little white spots). It is a strange idiopathic hypo-melanosis that takes this form, usually afflicting younger girls, almost exclusively below the belly button on the inner thighs although it can occur on the arms and it can afflict little boys as well. It has not real etiological origin that we know of, and tends to go away with age. The second photograph is a rash that I saw on several other children, which at the time I was unsure whether to put down to manchitas blancas or perhaps something like leishmania, giving the resemblance to bug bites. Later in the week I would sit down with Dr LaBrot and he told me my initial impression was half right, these were bug bites, the result of sancudos, a cousin of the mosquito who lives a similar lifestyle. Children pick at these over and over causing excoriations, and even though I was up the mountain alone with no guidance from the boss, the advice I had given to the mother to have the baby wear long sleeve clothing and use emollients (in their case, coconut oil which is easily available) was the right solution. The third picture, was a gentleman with chronic back pain, who had recently developed this nasty looking lesion on his face. It meets the ABCDE criteria to be alarming for skin cancer, and he needs it cut out. Believe it or not, in my inexperience and general hysteria I told him that I thought it was cutaneous leishmania that would scar over time and heal. I was very clear in telling him that I really wasn’t sure, and I even asked Jack for advice, as a local I thought he might have more insight if it was the effect of some insect I had no awareness of. This was my first proper blunder in the field. After showing this picture to Dr LaBrot after my return, he voiced some concern over this patient. How I didn’t consider something like melanoma, or even BCC, considering this man lives in the mountains spending literally all day in the sun feels like a pretty bone-head move. I would have to right my wrong with him the following week and send a letter up urging him to get it checked out and excised in Changuinola. Not my best work, but Dr LaBrot always had my back regardless. He expects so little of me (rightly so perhaps), that even when I make a gaffe like this he just preaches reassurance.

There was a handful of other cases up there that had me perplexed, a 15 year old boy with bilateral muscle pain in his lower legs and intolerance to exercise. I thought about some form of inflammatory myositis, wrote him a letter to take to the hospital asking for markers of chronic inflammation and prescribed ibuprofen to help him with the pain. His brother was eight, and had a limp for the last three months, and a slightly tender ankle to touch but didn’t satisfy the Ottawa ankle rules for an Xray. He could weight bare, with no discernible trauma to the leg, power and sensation completely normal. Again I had little other options. Once again I threw some ibuprofen at him for the pain (this time checking with the pediatric BNF what the tolerable dose was) and advised that he go into town for a specialist review and get some imaging. Also, I haven’t mentioned this already, but every child I ever saw would get a tablet of albendazole for worms. One dose every six months for any man woman and child was our policy. I felt like the candy man.

One patient, an older woman, was getting her COPD medications as part of normal follow up. She had been without her rescue and corticosteroid inhaler for two months since she ran out, and had been suffering a high symptom burden as a result. We went through inhaler technique, and I did my usual exam. Right as I was about to let her go she told me she had stomach pain. ‘Where?’ I asked. ‘Here on the left side, hurts when I walk, when I cough, all the time’ She said. We were in the Rancho, and laying her flat on the little bench and exposing her was not on the cards. I told her I’d have to come by and see her later in her home, and we could go through a full exam. This would wind up being my go-to strategy for physicals. There is just nothing like the experience of being in their home, at night, with the family at their bedside to give you a look into a patient’s life and how they are coping. As the boss himself rightly put it, those first five seconds when you walk in and glance around is a goldmine of context for the entire conversation, and your presence in their home is of tremendous value in building the therapeutic relationship. The feeling of wooden floorboards on my bare feet, the smell of their fabric and the vulnerability that me, a white man, was being let into was something that I never took for granted. As soon as this woman had laid flat and been exposed I saw it, a massive midline scar. When she pushed against my hand a lump the size of grapefruit projected out from the left of her naval. She was in constant pain as a result of it. She had given birth to 12 children, with two c-sections, but that didn’t explain her scar. An attempt to coax the details out of her was unfruitful

‘They took disease out of me’ she’d say.

‘Okay, do you know was it a tumour? Bowel or uterine? Anything?’ I would answer.

‘They took the disease out of me’

No luck. I told her there was nothing I could do for her, and wrote her a letter to take to Changuinola. She was obviously upset. I can’t imagine her COPD and chronic cough was helping either, so her inhalers might provide some kind of relief from pain. I felt for her. I think I would have felt for her if we were in Dublin in a wealthy neighborhood. Except this woman lived deep in the mountains, and any journey to Changuinola would make a six hour affair and a wicked hike for on old, obese lady in constant pain. I was also amazed at her patient file to find that her age was actually in her early fifties. I don’t know if it’s the diet, to sun exposure, the hard living or all of it together, but the faces of so many in these communities seem wrinkled decades beyond their years.

There was one other woman, younger, in her thirties, who came to me with five months of right sided chest pain. It struck me as slightly odd at first because it radiated to her head, right arm, and right leg. I usually call these 21^st century pains, meaning that there is probably nothing wrong that we will ever find, and a certain degree of neuroticism in the presentation is going to lead into an endless chase to find a cause. Like with any chest pain though I felt it necessary to do an exam, and so after bathing in the river, and setting up the hammocks, I came by to her house. It sat on wooden beams, making the home itself suspend two metres above ground, with a lower level that had a dirt floor, a couple benches and a hammock chair. She was there with her brother, her sister, and three children. She was also breastfeeding when I saw her. I asked her if I could examine her beneath the dress, and before I even finished, she had exposed her chest. I began slowly at the outer quadrant of her right breast, having watched Prof Hill at Beaumont do it a dozen times in an afternoon clinic. I didn’t have to go far, because right adjacent to her nipple was a mass the size of a big lime. Every attempt get around it caused her pain. She winced as I felt around its edges, irregular and hard. Thankfully she had no changes in the skin or discharge from the nipple. A tiny bit of further questioning painted a solemn picture. Her appetite had been low, and she’d been losing weight. Chrys, who was with me, sensed my grave concern. I told her she needed to get it looked at, and imaged. She had to go into Changuinola, make the hike and take a bus, or whatever means necessary tomorrow, yesterday if possible. She didn’t want to go, she had an infant child that she was breastfeeding (exclusively from the other breast), that she didn’t want to leave. I fumbled over myself trying to write her a letter, explaining the urgency of my concern. Chrys who was next to me preached calm and was the voice of reason. He explained to me that her roughly six hour trip would probably result in her getting an appointment and then sent home. We’d be better off if we took it on ourselves, set up her referral and then had her go down. How to communicate her referral though was the next obstacle, she had no phone, this wasn’t as easy as just giving her the date. Her brother who was in the room said he had a phone, and was willing to hop up onto the signal rock once a day to check for messages. That would be our guide. As I write this journal entry now we are back and forth with several people involved in general surgery and woman’s health, trying to coordinate a plan for her. She needs a mammogram stat. The thing about this case that has me thinking is how many others of these are out in these communities. What if I hadn’t set up my elective, and the team was still only doing medication drop off? When would this woman ever be assessed by anyone? She was lucky enough that this community was the second on our roster, if it was later in the rota nobody would have been there until probably mid-march. These people have to be out there, everywhere. It’s not as simple for them as having a problem and going to the doctor. If we don’t come around, nobody will. It’s a sobering thought.

That night at dinner, hosted in one of the houses by someone who had volunteered to cook our rice and cans of spam and tuna, I mulled all of this over. The house we sat inside was simple. A wooden table, wooden benches. Our horse-man Oligio had come to sit with us dinner and have some coffee, he was happy enough to just hang out, and I really appreciated that. I asked about his new years and he told me it was wonderful, the people all got together, ate and celebrated, covid not having reached them in any tangible form, and not a drop of liquor in the whole town. This was their way of life, up in the mountains. Some people would probably say that they are poor, objectively they might be right. There is not a lot of dollars, silver or gold up there. Instead they have their horses, their cattle, rivers, and traditions. They might not read Kafka, or study economics, but there is no reason why they should. Their way of life is what it is, and I don’t see a reason why they should live any other way. What they need is equal access to healthcare, and it’s a shame that they don’t, but I don’t pity their way of life one bit; it’s just different than my own.