Despite my fired up ruminations about living large amongst the jellies and the trees (oh I’m king of the trees), I am still a mortal man, and somewhat of a wimp at heart. Whatever microbial pathogen was to blame this time, my throat was swollen up so much that I could hardly sleep a wink, as I constantly woke myself with untimely snores and gargles—I would find out later there was a throat bug going around afflicting some other staff as well, which made me feel less wimpy—Thursday clinic at the base had a full list, and again Alison was to be my PIC. Getting the chance again to rest my mind and serve as translator rather than lead medic was welcome.
Our first patient was a pregnant woman, who brought in her a son with some kind of scalp infection. It resembled seborrheic dermatitis in its distribution along the hairline but was also crusted green like a kind of bacterial gunk. The boy was otherwise well and not losing hair, and we put the superficial infection down to bug bites and scratching intensely, which likely amongst the dirt of seldom washed hair was enough to introduce some secondary bacterial yuckyness. The reality is we didn’t know for sure, but like we do so often, we discussed conservative measures in almost more of a domestic mother kind of way than a doctor sense. ‘He looks fine, no fever, lets keep the hair clean and apply some cream. No need for antibiotics yet but if he doesn’t improve you know where we are’. Common sense was often the rule of law in these parts.
Our second patient was a complex case. He had severe testicular pain bilaterally for the better part of a whole decade. He’d already been into the bigger centres for three different surgeries over the past five years, and still his pain persisted. The poor man had to quit work because his pain was so intense. It was one of those histories that can be frustrating, because you know exactly what the problem is but also know there is just about nothing that you can do about it. I explained all this to him as best I could. The most we could offer was to get him a consult in a different specialist centre with a urologist. It turned out that was all he wanted. He knew it was outside of our scope and just wanted help setting up a referral and assistance for travel. It is such a relief to have a patient that understands our limitations as a practice. So many people in the communities already see us as such a step above the care they are used to (often no care at all), so it’s hard for them to envision that there are more steps up after that. If only they knew how many steps there was. Even the bigger hospitals in Changuinola and David still paled to the national centres in Panama City, and then of course for people with real money is the allure of Mexico or the United States. That’s one thing about the American health system that we have to admit, and it goes hand in hand with American capitalist values. If you got money, the best place in the world for you to get your care is in America, full stop. Be it good or bad, that’s the truth. I entertained myself for a moment with visions of some of my patients from the last four weeks getting off a plane in New York City or Chicago, the sheer mass of everything and what it would do to them. I can’t imagine.
A few more consults coloured our day, a child who was previously malnourished and now faring much better after a transfer of household from Mom to Dad’s, a gentleman in his twenties with post covid-syndrome (periodic shortness of breath resembling asthma that lingers for many months after a good whack of the Rona). Once Alison left around four another set of patients arrived, a mother and her daughter, both seeking separate consults. I was happy enough to see them and was optimistic I could get them both seen well by five in order to take a dip in the ocean before it got dark. Boy that was wishful thinking.
The first woman, the mother, had complaints oozing from every pore in her body it seemed. This hurts here, for the last five years when I do this. This other thing here, every few months it feels like this when I do that, also I am constipated, also it hurts when I poo sometimes, also… It can be so hard to even begin, and these are the times when that ‘golden thirty seconds’ that begin a consult turns into a golden five minutes, and by the time they’re finished you look down at your notebook a see something resembling the diary of Salvador Dali. I used a strategy for her that I learned while training for medical school interviews believe it or not, by an aging attending physician who was nearly blind from diabetes. He mentored me a lot in my application process and played a good part in convincing me to go abroad for medical school. I remember he once told me ‘If you’re good, you’re good, no matter where you train. I’ve met people who trained at Harvard and I wouldn’t let them tie my shoelaces’.
He showed me something he called the ‘bullet concept’ of dealing with someone who is upset or has complaints. It’s very simple and I use it both in business and in life. Your key question is always ‘anything else?’ With this patient it looked like this
‘Okay, absolutely. Lets deal with all of that, but before we start help me make sure I have it all so we can deal with them one at a time. What is the first and most bothersome?’ I asked
‘This pain I get in my shoulder when I raise my arm.’ She answers.
‘Okay. What else?’
‘This other pain I get here in my tummy’
‘Okay, anything else?’
It goes on and on. With every complaint you are taking bullets out of their gun. Eventually they will get to a point where they will have to say, ‘No, there is nothing else. That’s it’. Now their gun is empty, they are probably no longer frothing at the mouth, and it’s your turn to talk, except now you know everything on the agenda. No surprises. I was able to parse through each complaint one at a time, taking a dedicated history for each, before an examination for each. She had some generic muscle pains that didn’t concern me greatly, and some small hemorrhoids for which we talked about our good friends water and stool softeners. The consult took ages, and it was nearly getting dark by the time I turned to her daughter.
Her daughter, in her early thirties, had a long history of post-surgical pain at the site of a c-section scar. She talked me through how it was sore when she walked or when she did anything really. It sounded awful, and she had been to see a surgeon about it once and was told there was nothing that could be done about it. We spent a while talking, and like always I took a full set of vitals and did a general exam. I was almost ready to wrap it up after having spent close to twenty minutes with her when she dropped a little nugget.
‘It also hurts during intercourse’ she told me ‘and there is discharge down there’. Hmmm. Okay tell me some more I ask. She had a new boyfriend, of the last 7 months. Ever since he came along this abdominal pain from her surgery has gotten worse, and there is a yellow stuff with little sores on my vagina.
Well ya don’t say.
I brought her back to the examination room and a speculum exam confirmed that something was definitely going on. There was a thick white discharge at the cervix. A more rigorous history then revealed that although she did suffer from chronic abdominal pain from her surgery, palpation of her tummy now hurt more than it did before the discharge started. In the land of stop-dreaming-if-you-think-you-can-get-a-PCR for chlamydia and the other STI diseases, our next move was simple. This is Pelvic Inflammatory Disease as far as I’m concerned and she’s getting triple antibiotics. I had her sit while I prepped her ceftriaxone injection which took me ages, and made separate bags of meds with written instructions for her and her partner. He’d have to come back the next day for his injection I told her. He never did though, which is a shame. I finally gave her and her mother their prescriptions and sent them on their way sometime just after seven in the evening.
I slumped in the pharmacy chair once they left just taking a second to wallow in my fatigue. I had agreed to call an old friend that evening, and had a little over forty minutes to shower cook and eat before we’d link up. I almost for a second felt pity for myself that my day went so long and I wouldn’t have time to decompress. However, I was fortunate enough that I was living with an avid fisher and a native who grew up on a cacao farm, because when I moseyed up to the kitchen positively pooped from the day, the two of them were making pan roasted Mackarel with cacao coconut rice. We sat down and ate as a family over a round of beers. Just goes to show:
My life ain’t so hard
