The adrenaline based hangover lasted about a day, and by the time Friday morning came around I felt 95% of the way back to normal. I took the boat into town on Friday morning and sat down for breakfast at a local spot. There was a man sitting two tables across from me, an American retiree no doubt, draped in Hawaiian clothing and wearing a ball cap with a bald eagle. He walked with a crutch and we struck up a conversation, it was completely superficial; a hey-how-ya-doing sort of talk. He and his wife were in a rush to leave to catch the ferry. I caught myself thinking whether or not he might have been a veteran. I wanted to ask him about fear.
The day filled itself with tasks in wrapping up the week and in preparation for the next. Sam had been busy in meetings all morning, and by the time I finally saw her in the afternoon she was moving a hundred miles a minute. She pulled myself and Nicole aside.
‘Umm…’ She said in her softened Carolina drawl ‘So I just met with the board and… Well… You guys aren’t going to like this, but we’ve gone horribly over budget over the last two months. Everything that we’ve been doing, just today has been a mess. We can’t spend another shred.’
The classic dilemma of healthcare economics strikes again. I had a public health professor in college who once put things very bluntly. ’This is the fundamental problem with healthcare spending’ he said, ‘How do you consolidate a finite pool of resources, with a bottomless pit filled with expensive desires?’ Of course he was dead right. That was not a problem unique to us at Floating Doctors, and the premise that ‘resource limited’ settings exist only for the poor is a confabulation. All medicine is resource limited; it’s about where you set the bar. The Mayo Clinic in Rochester is a world away from Beaumont Hospital in Ireland, which is a world away from the hospital in Bocas town which is a world away from us. Sam’s words weren’t all that shocking to me when I heard them; although it wasn’t clear exactly what the implications of this development were. Sam didn’t even really know herself. As the three of us sat down and talked about how we’d have to cut costs a few things became clear, our practice was going to have to change.
No more paying for patient transports to hospital, unless someone is actively dying, we just couldn’t afford it. If someone needs to go to hospital they would have to find a way, at the very least I would have to stop actively offering our help for transportation, which I will admit was exactly what I was doing. I often didn’t even give patients the chance to try and source a solution on their own. My approach of ‘You need to go to hospital, we can send you there’ now had to change to ‘You need to go to hospital, find a way to get there’. This is where that difference in the bar I spoke about becomes visible. In the Mayo Clinic, they can’t afford the fourth surgeon in the theatre, in Ireland patients might wait months for an MRI because the machinery is expensive, here people couldn’t afford the gas it costs to see the doctor in the first place. Either way, the Ngäbe were many things, one of them was resourceful and one thing they were not is stupid. Most of them would find a way, it was just going to become an awful lot harder for them.
This development also meant that we would have to say goodbye to sending any kind of medication or bundles to the communities post clinic. Our work around was going to be bringing a condensed version of our pharmacy, a Noah’s ark of sorts, to every clinic. We had on site what we had, and those prescriptions would have to be made then. At the very least for one week I would have to make prescribing decisions for some more complicated patients without help from Dr LaBrot or Dr Nicole until she finished her isolation. Sam felt like the bad cop bringing us the news, but in reality I wasn’t worried. Another chance to overcome an obstacle, I thought. I look forward to it.
Our conversation was interrupted by Jack, who had just received a phone call, it was the patient we had transported across the Canal de Tigre. More specifically it was her mom. ‘The patient is no better’ was the crux of Jack’s message. I got him to bring the phone and set it down between myself and Nicole and we put it on speaker phone.
She had been out of hospital now for just under forty eight hours and felt the same as she did when we brought her in. Since her discharge from hospital she hadn’t eaten a thing, as her nausea was so intense. For two nights she hadn’t slept and the ibuprofen tablets were effective for increments of several hours before her fever and pain came raging back. Mom was asking us what to do. She needed to go back to hospital for sure, get some fluids in her at the very least with some bedside monitoring and an actual decent treatment plan for her infection, but we had no guarantee that things would be any different this time than the last. Nicole, myself, Sam, and Dr LaBrot via telephone met and brainstormed her options. Mom was keen enough to go to a different hospital, even if it meant making the trip to Changuinola two hours away from her relative’s house where she was staying. Of course we were now looking at a post budget-cut world, so they would have to figure it out. Not a great position for them to be in. We debated this as a group and decided we could squeeze the bus ticket into pre board-meeting habits, since this was a continuation of care from when our practicing guidelines were different (I love when technicalities work to my favour instead of against me).
Ironically, when Sam showed up at the meeting point at the bus stop, our patient was nowhere to be found. She asked every woman in sight. Our patient had found other means and caught the bus already. It was a timely and poetic display showcasing one of the most important principles of healthcare:
It is lovely helping patients, but it’s even lovelier when they help themselves.
