For anybody who has tried to reach me on whatsapp this week, I am sorry for not responding. I also apologize to those of you who enjoy photos; you will notice that none of the following posts have any. Also I checked myself on the scale today in our pharmacy, and realised that I’ve lost six kilos in the time that I have been here. I have never been this lean before. The reason for all of this will become clear soon enough.
Our fifth deployment to the mainland community of Ensenada was predicted to be a challenging affair. The community is at the ithmus of a peninsula forming the eastern most point of the Chiriqui lagoon. We were anticipating a boat ride with its fair share of bumps—The peninsula has a jaw-like cavitation that forms a long bay, and the entrance to that bay is called the Canal de Tigre. It is a converging point for a series of ocean currents that produce the largest swells and most difficult navigation anywhere in the archipelago—Furthermore, the community itself is quite large, and fairly isolated, often requiring a four day clinic week to service all the people from different edges of the bay. Dr LaBrot told me that on a given week during normal operations, if they had a crew of three doctors, he might be worried that it would be too much work for them to get through in the allotted four days. How lucky were they now they’d be getting a student medic, a clinic manager in training, and a brand new member of the Floating Doctors team: Iraida, a soft spoken local from Almirante not far away.
The morning we sailed out was easy enough. As always there was rain, like death and taxes. Arriving on site we hauled our gear out of the boat. The locals were already lining when we arrived around 930, and they helped us get our things into the rancho. This was a different set up than we usually had. There was an adjacent schoolhouse that could be used for examinations right next to us, and the rancho had plank wood walls, instead of the usual open concept. We were essentially half indoors however, as the back end was partially open with a neighboring structure’s roof cutting in around a meter below the ceiling. A quick huddle with the team to designate jobs allowed us to set up quicker than normal, a good start by any means. You would have never guessed that it would turn into the most challenging day of my career in short order.
The first patient I saw was a young guy, twenty, with a strange presentation of full body pains during urination. These episodes came on a few times a month, lasting a full day, and gave him increased frequency of urination and odd muscular manifestations. One day around a month ago, he was walking and spontaneously lost control of his lower limbs for half an hour. This all according to him. His examination was completely normal when I saw him except for a strange basicity in his urine. I put it all down to an electrolyte imbalance not knowing what else to do. Even if that was the cause of his symptoms, the real question beckons as to why, and that I could not answer. I gave him a letter to take with him to get some blood work done in hospital to have closer look. When I offered to take a look at his genitals, seeing as his symptoms urinary, he got oddly defensive. It always find that somewhat annoying. I’m not doing this for me dude. Why you gotta make me feel weird for asking?
The second patient I saw was a lady with abdominal pain who just found out she was five weeks pregnant. This is always a highly concerning sign, and an ectopic pregnancy has to be first on your list of differentials. I spent ages with her flushing out the details of her symptoms and doing very careful examination. I led her out quickly for an examination of her abdomen. I couldn’t find anything terribly concerning, although she had some tenderness at her renal angle (the part in your back where you ribs go away and the bottom half of your kidney is exposed against the muscle), which is an indicator of kidney infection. Her urine was clear however, and her symptoms just didn’t line up. I was confident enough that I ruled out both a kidney infection and an ectopic pregnancy and I walked back into the rancho; or should I say tried, because there was people blocking the path and the door spilling out from inside. The place was packed. I had taken over an hour to see the first two patients, and a rapid thumbing through the charts showed that we had twenty-seven people registered already. Twenty-seven at 1030 am. I told Jack and Iraida right away, we’re closing the admin desk. We’d offer a million apologies to anybody else who shows up, but that’s it. I also told them to go through the numbered charts on the list, and tell anyone whose number is higher that fifteen to come back at three. That might help to ease the stress, I thought.
It didn’t
One after another, difficult case after difficult case sat down in front of me. Asthmatics of forty years who had run out of medications with a wheeze so loud I couldn’t hear her heart valves, a farmer with a torn hamstring who had been walking through the pain for two months, a man with a previous hernia surgery who was having a recurrence of pain, another farmer whose right foot spontaneously stopped working for no reason two months ago (something we call ‘foot drop), a pregnant woman and her mother who started crying when they heard the fetal heart rate on my hand-held Doppler ultrasound. Every time I fell behind farther on the list. By the time our numbers fifteen plus were coming back after lunch I had gotten to number eight. Then I saw a sixteen year old that was pregnant for the second time in two years.
She was a girl I had been told about before I came. She had a tragic backstory. At fifteen she got pregnant, and was seen by us during one of our regular visits. Things were trending well. What we didn’t know at the time was that she was in an abusive relationship, and her baby’s father was spiralling out of control. One night he beat her to bits, deliberately punching her in the stomach until there was nothing left to hit. She suffered a traumatic abortion and had vaginal bleeding for a week until she presented to an emergency department a long distance away. She had an evacuation of the fetal components under general anaesthetic, eight weeks pregnant at the time.
This time she was seven months pregnant, and the ex-partner was now on the run from the authorities. She came to me with her mother, and mom did most of the talking. She had a two week history of smelly discharge from her vagina, and blood. She had no fever, but yesterday began to develop pain in her abdomen. When I asked if she felt the baby moving she said that it used to move a lot but not so much today – an ominous sign. It doesn’t take a genius to deduce that the infection she had downstairs was spreading.
I brought her into our private room and had a look at her abdomen. She was tender in the suprapubic area, right around the uterus, and the baby’s head was wedged right into the cervix where it should be at the gateway to the outside world. A Doppler ultrasound confirmed my fears, and heightened me into a near state of panic. Its heart rate was 172 beats per minute, absolutely flying. This only happens where there is something wrong, usually an infection in the amniotic fluid. An infection in the amniotic sack, something we call chorioamnionitis, is code red for the baby and the mom. If the bacterial load is bad enough the baby can die, and all that tissue starts to decompose, creating a nidus for necrosis and infection. She would then give birth to a stillborn, or worse, go completely septic herself. Oftentimes the only good solution for chorioamniontis, especially when the mom is this far along, is to induce a premature delivery under controlled conditions. That was a decision to be made by an expert in this field, with the safety of medical equipment at the bedside. If she didn’t go hopsital today, we got closer and closer to fetal death. This woman has to go to hospital today. I debated suspending the clinic, but before making any decisions I asked them to wait. I took my phone and walked towards the one rock with service, a hundred metres away. Service was fleeting, but I managed to send a text and the boss responded with approval. Okay then, here we go.
I got Jack, our designated facilitator of patient transport, and brought him into the examination room. The four of us sat silently inside the little schoolhouse with two inch gaps between its plank wood walls. I tried to find the right words and spoke carefully.
‘I am worried’ was the first thing I said. ‘As I’m sure you already know, there is an infection down there. This infection for the moment is not very bad, but the problem that this poses is the connection to the uterus. For two weeks this infection has been spreading, and I think it’s gotten to the baby. His heart is racing. I am not saying this to scare you, I just want you to know that I am worried. I think you need to go to hospital today. Now’
‘Today?’ Mom asked ‘How are we to do that? Who will go with her? Where…’
Jack asked if they had a boat, and they said no.
‘That is not for you to worry about.’ I said ’This is what we do. We are a medical service. We will rent out a boat for you if necessary, we can facilitate all of that, but you need to go today. Not tomorrow, but today’
‘There is a boat every Friday. We can’t go today’ she said ‘I cannot go with her, I have other things to do. Friday is much easier’
Back and forth we went. ‘Oh no because of this’ and ‘who is going to do this’. They weren’t getting it. I could feel my own blood pressure rising.
‘Listen’ I said as I looked Mom straight in the eye ’We are not going to force anybody to do something they don’t want to do. But you need to understand, it is my medical advice that you need to go right now. You can choose to go whenever, or not go at all, but understand that if we do not go today then we risk losing the baby, it’s very simple’
‘Oh no but what about…’ She began.
We were going in circles. As a medic it’s not an easy place to be, when you feel so strongly and just can’t seem to get in line with the person sitting in front of you. I wasn’t happy with the outcome but that is just fine. I respect their decision. They don’t have to do what they don’t want to do. I’ll be honest when I say that I nearly stopped listening, because I knew that our discussion was already finished. I offered them a compromise, to take the boat back to Bocas with us tomorrow Wednesday at least, instead of waiting until Friday. I just wanted to make sure that the decision was coming to the right place, so I turned to the daughter herself.
‘What do YOU want to do’ I said
‘I want to go tomorrow’ she said. Plan made. I made my peace with it. It was their choice. I thought about breaking for lunch but decided against it. It was now close to three pm and we were still not even one third through the list. Just a few more I thought, then I’l eat. I moved on to the next patient
