One of the things I was beginning to notice on our deployments was how dire the situation had become for all things prenatal in these communities. It was thought that in the darkest shutdowns of covid that the chronic disease populations would suffer the most, with no way to keep an eye on their diseases that so often go uncontrolled, leading to long term detriments. That is part of reason why Floating Doctors established their chronic medication drop-offs, and it was why the team was so excited at my arrival; it represented a chance to begin righting the ship for those who hadn’t had a blood pressure or a glucose check for close to a year. I saw many of those patients, and while it’s true that some of the diabetics now had hypertension and some of the hypertensives now had deranged sugars, for the most part things were stable. Some modifications were made sure, but these people understood their disease state, and a lack of monitoring wasn’t going to change that. It was pregnant women that I believe suffered most. The amount of pregnancies that were now seven months along, never once having an ultrasound or prenatal vitamins was alarming. In my five weeks so far I’d seen countless yeast infections, STIs, menstrual issues, and under-nourished pregnancies. Ensenada was like the mecca of all this.
My following victim was also a pregnant woman, who looked like she might go into labour right in front of me. She was seven months along, and had vaginal itching for the last week. As I took her history she told me about how she began with a new sexual partner at the beginning of the pregnancy. She developed a full on vaginal infection with discharge, blood, a raging fever, and abdominal pain just after nearly six months ago. ‘It felt a lot like this I am having now, just a lot worse.’ She said. An abdominal examination showed that her uterus was two months bigger than it should have been. This made me suspicious. One of the reasons for a larger belly than your dates is gestational diabetes, a product of the parasitic arms race between mother and baby.
When a woman gets to the eighth week of pregnancy, the placenta begins to secrete hormones that alter the biological makeup of the mother. This is done in the baby’s interest, securing resources for growth and development. Among those is a compound called human placental lactogen or hPL. The function of hPL is to decrease the ability for the mother to extract glucose (the cell’s main source of energy) from the blood stream. This raises blood sugar in the blood, enabling the fetus easier access to energy as blood circulates through the placenta. When this goes a step too far, which can happen for many reasons, women get what we gestational diabetes. This poses significant health risks to the mom, and creates huge babies that fat around the waist. So big in fact that they get too large to exit through the pelvis during birth, which is bad, bad news.
Sure enough, a finger prick revealed glucose was four times the diabetic threshold. This was now a high risk pregnancy. I could try and treat her vaginal infection, likely a yeast infection due to all the sugar leaking out in her urine, but she needed to see a specialist. I asked her if she’d be willing to come with us to hospital tomorrow in the boat, and she agreed. So passed another long consult that compounded my stress.
The following patient I saw had intractable nausea for the better part of two months. She couldn’t eat a thing, because it would come back up immediately. She had gotten pregnant four months ago, stopped having periods, and for the last eight weeks she’d only eaten a few bites of banana a day, which was all she could muster. Previous pregnancies had given her a little bit of nausea she told me, but never like this. She looked very thin. I began with all the standard pregnancy questions, her menstruation, was the pregnancy planned or a surprise, had she been having pains, ankle swelling, and all the rest. Then we moved on to her exam. She laid flat on the office desk in the schoolhouse and I pulled up her shirt. I felt around and found nothing. No masses, no uterus, no nothing. This woman wasn’t pregnant at all. I tried to mask my confusion and still went through the process of using the Doppler to no avail. There was only one thing that occurred to me could be the cause of her symptoms, something that we call a molar pregnancy. It is when an improperly fertilized egg lodges into the wall of the uterus as if things were normal, only it begins replicating at an alarming rate with deranged cellular architecture. This causes a massive spike in pregnancy hormones up to twenty times the normal volume. The levels can be so high infact that urine pregnancy tests get so confused they give a negative reading. One of the by-products of a molar pregnancy is something called hyperemesis gravidarum, which is a fancy word for out-of-this-world morning sickness. These women vomit around the clock, and enter a state of starvation, breaking down proteins in their cells for conversion into energy. It can be very dangerous. Whether that was the cause or not, it didn’t matter, she needed to see a specialist. I didn’t have the ultrasound I needed to confirm or deny her diagnosis, and there was not much else that I could do. A urine pregnancy test came back negative, and to say that she was shocked was an understatement. We had a long discussion about it.
‘What do you mean I’m not pregnant’ she said. ‘I haven’t had my period in four months.’
‘I am just as stunned as you are’ I answered ‘I think its best that we get you to see a specialist that might help us figure it out’. Another woman added to our boat list for tomorrow. She wanted to talk more about it, and I tried my best while cutting the conversation short. I still felt the weight of dozens of waiting patients heavy on my shoulders.
One of my next consults, the first straightforward one of the day, was with a child named Chichi. Chichi was fine, but I had noticed chichi was a common first name in my time here, particularly infants. I saw loads. I turns out, that the Ngäbe word for baby is chichi, and many of those children I saw didn’t have their own names yet. To the Ngäbe, it’s considered bad luck to name a child that young. Some perceive it as arrogant, to give them a name when so many of them will die before they reach the safety of childhood. It’s a sobering discovery. I thought of all the nameless chichis I had seen and treated, and all those mothers who understood that giving them a name was premature.
We were now approaching the evening, and people were getting frustrated. Between patients I walked out to grab my pen from the admin desk, sanitize my hands and put on gloves, and when I turned back around there was an older man sitting in my chair. He was engaged in a heated argument with Jack.
‘I came from far away. I don’t live here!’ He said shouting. I noticed he had a cane. ‘I came here to be seen and I am going to be seen.’ The rancho fell silent as him and Jack went back and forth.
I usually try to stay out of these confrontations. We need to have a bad guy, to keep order. That guy shouldn’t be me though. Jack was a native, he knew the temperament of these people, and I was the doctor who needed to gain and hold their trust as best as possible to give decent care. If someone was going to tell people off, it shouldn’t be the foreigner doctor. My day was already so insane though, and Jack for all his kindness was just not getting anywhere. I stepped up next to him and put in my two cents. He might not respect us but I had to believe that he respected his village.
‘Sir, do you not understand that everyone in this room is waiting just the same as you?’ I said gesturing to all the other people sitting silently in the rancho, now watching. It’s an odd thing to be in a position of power as a twenty six year old, giving lip to this old man who probably lived my life three times over. ’Everyone here has been waiting, all day. I understand your frustration and I am sorry. I am going to see everyone here, even if I have to stay until six o’clock tomorrow morning. But I am going to see people when they are the next in line, not when they want to be seen. I will get to you just as I will everyone else. I apologize.’ My legs were trembling. I don’t like confrontation.
‘Okay’ he said. Not so much as a rebuttal. He got out of my chair and took his place outside with everyone else. I would get to him later and he wound up being a very pleasant man. I think he was just a big personality in a small town, if you get what I mean.
All the while a rainstorm battered the walls and the roof, flooding us with an air of dampness and cold. We motored on and on through the list, and as light became dark, the walls of the rancho made our treatment area like the inside of a cave. As energy faded and anger turned into fatigue, the chatter was distilled to a minimum, and the patients sat in silence as the three of us scurried in the dark with our headlamps on like little termites. The back wall that was half open was pouring water right onto the chair where I had left my notebook and blood pressure cuff between consults. On and on I saw babies, elderly, young, male, and female.
Finally, at 11pm as the last patient on the list was let go, I stood there for a moment in silence. I hadn’t eaten anything all day. I felt a pressure in my abdomen, and as my mind processed my physical state I realised I hadn’t even once during the day taken a break to pee. After stepping outside to do my business, Jack brought me a bowl of cold dinner and a cold cup of coffee. I’m not usually a coffee drinker but I figured it would do very little to keep me awake with the fatigue that was now just setting in. I sat in the corner, in a little pupitre, and ate in silence. Jack and Iraida were running a sex ed session in the other end of the room, and I was hoping to God that nobody would ask me for anything. I was zoned in on that meal like a zombie, or a drunk. Any disturbance surely would have not been well received. As I loosened, my mind wandered to my childhood, when I was a small kid in Canada. My mother, who re-trained as a resident after we moved, would regularly work on call overnight. I remember she would come home to a family of three screaming children that would batter her as soon as she walked in. At that age children are more like dogs, with no presence of anything that happens outside their walls. After one too many batterings my mom instilled what she called ‘the coffee rule’. When she came home, we were not allowed to disturb her for any reason until after she had finished her cup of coffee. This was a hard rule, enforced strictly. I remember we would bop all over the floor, doing those things that children do, and I would get up on my tiptoes just to see above the rim of the mug on the table, making a quick assessment of how much time remained before the cup was finished. For the first time in my life I felt like I understood her rule. In an odd way, I felt a connection to my mother even though she was thousands of miles away, like I had gained an insight to her life away from home that told me so much more about her.
We still had house call to make, across the bay, and we would take the boat out in the dark. The man in question was bedridden, and our time limitations determined it was best to see him now and not tomorrow.
Getting across the bay in darkness wasn’t the challenge, it was finding the house amongst the black of nothing without getting to close to shore and risk damaging the boat that gave us issues. Using my headlamp as a spotlight we combed the coast in search of anything. We wound up at the wrong house at first, and nearly decided to call it off before we finally saw a flicker of light from a dock shrouded by flora on either side.
The house call was an older gentleman, in his seventies. Having private insurance through his employer meant that he was already on a decent cocktail of medications for coronary artery disease. The reason he wanted to talk to us was because he was bedridden. Two weeks prior he had been working on the fields, and he stepped into a sinkhole with his right foot. It had been terribly swollen for the last two weeks and was so sore that he wouldn’t walk on it. A quick examination showed us that he had a high ankle sprain, not an uncommon ailment. The ankle has two collections of ligaments, one on either side. On the inward side, there is a combination that forms the deltoid of the ankle, and these ligaments are so strong that they seldom ever sprain. An orthopedist once told me that you are more likely to break bones than tear those ligaments should you encounter a force strong enough to do damage. On the outside, there is a different series that is quite the opposite, in particular the anterior talo-fibular ligament which runs along the top of your foot, is the most common ankle sprain that we see. Most support braces that you will find in common grocery stores isolate this group in particular. I didn’t suspect any kind of fracture, but only an Xray would tell us for sure. This gentleman was happy enough to get himself to hospital sooner before later, something which makes our job easier. It’s always nice to help people, but it’s ten times better when your patients help themselves. He was friendly as they come, and exactly what I needed after such a stressful day.
The boat rumbled back across the bay in darkness, and we set up the hammocks, I looked down at my watch and it was nearing 1am. My alarm was set for ten to seven, where we would get some breakfast before setting up clinic at 730 before starting up again. Rain came in hard flurries overnight, with the fluctuations of humidity and pressure causing the ceiling to squeal and creek throughout the night. It almost sounded like laughter, a sinister and creepy kind that cut into my sleep without warning. I was absolutely knackered, and as I laid there in suspended animation, I thought about the day. It was a wild one, I thought. The toughest of my career so far, no doubt.
But I loved every minute of it.
