Sexually educating a group of horny teenagers went as well as I could have hoped. Having never led a sexual education class, nor feeling qualified in any manner to do so, I did my best to touch on the basics:
‘Lads please don’t put your things in places where they are not wanted.’
‘Be explicit, we don’t want surprises.’
‘Even if a woman is on family planning injections those do not prevent infections.’
The reality of this situation is that even the lads present who were twenty-two probably had already fathered children, so if anything they might be the ones giving me some lessons. At one point while I was chatting Jack brought me a banana, and a handful of condoms. Getting some headlamps properly oriented to for proper lighting was the hardest part, as surprisingly everyone stayed impressively mature during the demonstration – something I was not expecting.
‘Lads just remember the bubble at the top’
‘For God’s sakes don’t forget the bubble’
After the infomercial, it was late. My chance to bathe in the river had all but passed and we had already missed dinner. Jack urged that we rush over to where our food was prepped so as to not keep the ladies who made it waiting. Dinner was cold when we got there, the classic rice and lentils, a floating doctor’s classic. On my way back from dinner, I walked slowly, like I usually did after clinic, and studied my surroundings closely just to appreciate how incredible everything was. My contemplation was cut short, by a man speaking loudly, almost yelling, from one of the houses along the concrete path. It was a typical wooden house but with unusual star shaped windows. He was shouting about Martians and salvation. I realised quickly he was giving a sermon. It was 10 o’clock at night.
Anselmo had told me that many of the Ngäbe were actually raised Christian. Apostolic churches were common as well as the odd catholic, Jehovah’s witness and latter day saints. I was a bit surprised at first to learn that there were no active indigenous religions, which I found slightly disappointing. I would have been so excited to hear about their animal based deities and myths of genesis. There was a local religion for that matter, Mama Tada, which is a blended Christian spiritualism that derives from an apparition seen by a Ngäbe woman in the 1960s. I suppose it wasn’t something that should have surprised me, that Occidental religion ran the show. I noticed early in my time here that the vast majority of Ngäbe people had European last names like Morales, Smith, Johnson, or Quintero. This is not because of slavery, like the many people of African descent who inherited names from their owners in other Caribbean islands, but rather from national registration. In the earlier parts of the twentieth century when national structures for social security came into place, the only way to access them was through registration which required a first and last name. Many of the indigenous didn’t have last names, as was not the custom. So they took names that they liked from British and Spanish merchants. I wonder what I might have picked if I was here during that time. Juan Schwarzenegger. Hasta la vista baby.
I sat silently on the concrete path and shut off my headlamp, wanted not to be seen intruding on the sermon. I was immensely curious about the relationship that different cultures have with their religion. I always ask myself which one came first; did the religion shape the culture or the other way around? For example, the traditional Ngäbe dresses that many women wore were introduced by European missionaries centuries ago to preserve modesty in a culture where people walked about naked with loincloths, and now everyone bathes fully clothed in the river in something that has become cultural norm outside of faith. Versus when the Jewish tradition prohibited eating pork, a move likely more attributed to the risk of developing food borne diseases but dressed up in the attire of faith and holy purity. On the contrast to religion being the source of all things, I also recognize that in small town like this religion sometimes becomes the place for spending time because there is not much else to do, something I had once experienced firsthand.
When I was backpacking in the south of Brazil I stayed in a small town called Prudentopolis. In that part of Brazil and the north of Argentina there is a geographic band across the subtropical jungle where many European communities settled at the turn of the century. Prudentopolis was interesting because it was a town made up almost exclusively of people from Swedish and Ukranian descent for one hundred years. Somewhat jarring it is to walk through a town and see orthodox Christian architecture, Ukranian pickled foods in all the shops, and everyone six feet tall, blonde with blue eyes speaking to you in intensely thick Brazilian Portuguese. The town was so small there was actually nothing to do, at least not for a backpacker like me with no car or means to hike. At the local museum (on the Ukrainian migration of agriculturists), a lady at the front asked me if I would like to join the town at mass. So went my big event of the day, a dense Brazilian/Ukrainian hybrid mass given in an orthodox church in Portuguese. There was about six people there and me. I’m not a religious man by any means, but if I’d had been invited to mass here in Norteño I’d have joined in a heartbeat.
Getting back to the rancho I saw a little group huddling near the ground in the corner. It was the rest of the team, and a few locals. Sam was playing with two kittens. My friend from earlier that day, the friendly gentleman with query HIV who seemed odd and exhibited some frontal lobe signs was there. They were his kittens he told me. I showed face and said hello below prepping myself to go to sleep, setting up the hammock. Just as I was going to crawl in he came to me and got close.
‘My grandson, he is very sick, with fever. All day. Can you come see him?’ he said. I found this somewhat odd. Why tell me this now? I had already spent almost an hour with him earlier. I told him to give me a minute, got my things together, and walked with him up to his house just next to the rancho.
We climb up some steps and I am greeted by his daughter, who shies away from any eye contact and looks directly at the floor. My friend leads me from the main space across a small wooden plank that bridges to a detached chamber on separate beams, and walking through a doorway we enter a small room. I look down to find three children sleeping on the floor, just with a small blanket underneath each. No pillows and no beds, the smallest had a tiny hammock. They gesture me towards the middle one, who is in the fetal position, he looks to be between 18 months and two years old.
Just on touching him I can feel that he’s burning up with fever. My friend does all the talking, while mom remains silent. He was having cough, diarrhea, a little bit of vomiting but not much else. He was eating well at least for his standards.
‘Has he been crying, jumping, playing?’ I ask.
‘No’ mom interjects ‘He’s paralysed.’
‘What?’ I babble. At first I convince myself that I misheard, like we often do when we hear something shocking.
‘He cannot use his legs’ My friend replies ‘Look at the back of his head. Surgery, many years ago at birth. He has problems’
I look down at him sleeping and see that he has a scar at the back of his skull, unlike anything I have seen before from surgery. It’s not a VP shunt, like the patient I saw in Bisira. Located at the base of the occipital bone, the bottom-back part of the skull, I don’t have time to really contemplate all the things it might be. They certainly didn’t seem to have the details.
An axillary temperature reveals 37.4, which is a fever when considering that axillary (armpit) temperature is reliably 0.3-0.5 degrees lower than oral temperature and close to 1 below rectal (the most accurate). Trying to pick him up is like handling a dead fish. I have used that terminology so many times because I’ve heard it used, but never really understood what it meant until that moment. This child couldn’t support the weight of his head, flopping loosely no matter how I tried to hold him. I found it impossible to even sit him up, as his frame had the rigidity of overcooked spaghetti. All the while he made not a sound, inhabiting a transitory space between asleep and awake. Sam, who had just arrived, had to hold him steady sitting up so that I could even listen to his lungs. His lungs were crackling, which denounced he had infiltrate of some sort.
‘Is he always like this?’ I asked. Determining a baseline would be important here, and if he’s got severe disability and an always floppy posture, his lungs could be chronically infiltrated by fluid that he’s unable to clear.
‘Oh yes’ they told me.
This infant likely had some kind of long term deficit, which if impacting his muscles could mean that he never properly expanded his chest to take fully deep breaths. He could always have fluid in his lungs, even when things are fine. On the flipside he does have a fever, so this could be pneumonia. Also, something I didn’t even consider at the time was that his vomiting could mean aspiration pneumonia, which is when things go into the lungs that shouldn’t, providing a nidus for infection (this is always a higher risk in people with disabilities that could prevent them from having a strong cough reflex, like this child). This could also just be gastritis, a little stomach bug, and I was being thrown off by his baseline normal fluid in the lungs. In infants urinary tract infections can present in all sorts of weird ways as well, and had to always be ruled out. Any number of things could have been the culprit, and without knowing his normal I was walking in the dark.
In cases like this, you can’t just tell them to sit tight and come back in a few days if things don’t get better. This is it, we were leaving tomorrow, and so I made the decision to prescribe antibiotics. Amoxicillin three times a day for a week. Whatever is in there, whether it’s a lung bug, stomach, bug or uninary bug, this would cover them all. I explained everything to the mother and she stared blankly into space. At one point she closed her eyes, seeming to fall asleep while standing upright in-front of me. I prepped his medications and came back up to the house before giving instructions to both grandad and mom, who were both incredibly strange and certainly impaired. There is not much else you can do but hope that they can keep up and treat the infant. It’s now in their hands. When I got back to the rancho I made a patient file for the mother as well. I wanted us to have a record on her, and when the next clinic came to town in three months’ time I want her to get assessed. Such an odd family needs to be on our radar for next time. If we don’t look into what is going on there no-one will.
Walking back to the rancho I brushed my teeth and got ready for bed. One of the kittens was still kicking around, coddling up to my backpack when I put my toothbrush away. I had nearly one leg up into the hammock when Sam called my name.
‘Hey Juan. That lady for the house call is here now’ She told me.
Right, I had forgotten. There was a lady that I saw during the day that needed a pelvic exam, and we agree to come by for a house call after clinic. I had sent Sam to find her before we started Sex Ed with the lads, but she was out. Now at eleven I suppose she’d finally caught word that we were looking for her. She told us we could go up to her mother’s and take care of everything there. Walking through a five minute path of rocks, stepping over creeks and climbing grassy mounds I reminded myself the details of her case. She was young, late twenties, and had abdominal pain for the last three days with vomiting and vaginal bleeding. She also had pain on intercourse, a deep pelvic pain, in contrast to pain on entry which is less concerning. There was a little bit of clots in the bleeding she had told me, but it was not a huge amount and there was no discharge or funny colours. One of the first things she told me, before I even elicited the details of her history was that she had miscarried her last pregnancy in November. A deeper dive into her obstetric history was fairly noteworthy. Five pregnancies, three of them to term, with a miscarriage last November and an ectopic pregnancy that was aborted in January. The ectopic pregnancy was what frightened me.
In the normal fertilization process, an egg is fertilized in the ovaries, or just adjacent to them within the fallopian tubes. These tubes descend into the uterus where this fertilized egg (now considered a zygote), embeds itself into the wall of the uterus to begin what we consider ‘the pregnancy’ which is contrary to the popular understanding that pregnancy begins at the point of fertilisation. Many eggs can go fertilised that do not embed into the uterine wall and nothing becomes of them, and its only when the egg becomes embedded that we pass the point of no return and set in motion the cascade of events that results in the growth and development of a human baby. Sometimes, for a variety of reasons ranging from anatomical to influenced by disease or scarring of the tubes, this pregnancy (zygote embedding in the wall) occurs inside the tubes instead of in the uterus. This is a surgical emergency. As the fetus grows inside the limited diameter of the tube it is a near certainty that it will rupture, causing a massive hemorrhage that will kill the mother and the fetus. They need to be aborted medically or surgically, stat. Any woman of reproductive age with stomach pain that presents to clinic is an ectopic pregnancy until proven otherwise. This woman, by virtue of having had one already, was at massive risk of having another. Her last menstrual period was four weeks prior to the onset of her pain. I wanted to make sure I had all my bases covered before I let her go.
So we walked through the dark and she settled in an outdoor roofed kitchen outside her mother’s house. There was a table there, and I explained the situation to her, that I wanted to take a look down below. Beginning with a pelvic exam she had no tenderness of the cervix, a great sign that made me feel better that she don’t have some kind of uterine infection. She didn’t have any appreciable masses or lumps in her uterus from what I could feel which helps to rule out that there could be a mass contributing to her bleeding. Finally on speculum examination I found no discharge or blood at the cervix, and the external os was closed, which meant that she was not in the process of actively miscarrying another pregnancy. All of this made me feel reassured, and I explained it all to her as best I could. The next morning she came by for a pregnancy test and a urine dipstick to rule out a urine infection and double check her hormone levels. My diagnosis was that she was having a particularly rough menstrual period. I remembering telling her this and feeling slightly under qualified.
It was a sensation I knew well from my time in Drogheda with the Obstetrics and gynecology team. I’ve never had vaginal bleeding, or a UTI, nor will I ever get pregnant. I also don’t know what it’s like to get bloating or mood swings from the menstrual cycle. I remember I told a friend once that I felt silly giving advice on to women on their anatomy as a man.
‘Think about it this way’ he told me ‘You’ve never had cancer or COPD, yet you tell those patients what to do.’
‘I still got lungs though’ I retorted. Check mate Billy. I win.
I remember having a similar discussion with one mother, who was having a cup of tea after we had delivered her first child. She told me something different.
‘In the last month alone you’ve seen dozens of vaginas’ she said. ‘I’ve seen only one’.
I suppose that much is true
