Our third clinic of that week, which was taking precedence over Thursday base clinic, brought us to the neighboring village of Valle Escondido. It was the same community from which most of our staff came, a simple five minute boat ride across the first bay on the island of San Cristobal—whom by the way, I only found out yesterday in a conversation with my mother, is the patron saint of travelers. According to legend, San Cristobal (Christopher) was a very tall man, who dedicated himself to serving Christ by helping people cross a treacherous river in which many feeble travelers perished by carrying them on his shoulders. He did this for a time until one day he helped a child in need of crossing. Allegedly, when he took the child on his back and began wading through the water, the river swelled unlike he had ever seen before, and with every step he took, the child turned heavier and heavier as if he was made of lead. Cristobal nearly drowned in the process. Having safely crossed, the child revealed himself to be Christ, and then vanished. His journey represents the weight of the world on the backs of all those who are of good will. This is why images of San Cristobal carrying a child are commonly worn in bracelets or around the neck. Seems like a fitting enough name for the island where our medical boats commonly sail out of to transport the ill—it was a relatively easy community to service by virtue of its proximity to us and Bocas town. The likelihood that we would encounter really sick patients who have held out for months and months with decaying health was not as high – at least that’s what I had been led to believe.
It was a really enjoyable clinic, because so many of the people in the community already knew me by name. Unloading our materials and carrying the pelicans through the path down into the central rancho was a different experience than anywhere else. People would see me walking up the path and call to me just to chat. Our security personnel who were off duty, our many cooks, family of our workers, or patients I had met previously at clinic. It filled me with a certain sense of pride, like I had earned my stripes and now really won the respect of the people in the community. This carried on throughout the whole day, when I walked around between patients, or when people passed by the rancho on their way.
The patient load was fairly light by our normal standards. Management was really cracking down on our time limitations due to the scarcity of funds to pay for overtime, and this caused an unfortunate degree of confusion for many of the patients. So many of them were used to turning up and being seen happily, which was the Floating Doctors way. Regardless of your age, gender, or ailment, whoever wanted a consult got one, with staff and intake personnel capable of giving patients extended consults to discuss the finer points of health and lifestyle amongst the hard complaints of pain and symptoms. This was the first visit resembling a clinic for a full year to them, and many patients had to be turned away because they didn’t have real complaints (contrary to popular belief, saying ‘I want to a see a doctor to check how I am doing’ doesn’t constitute a medical need, per se), or at best were offered paracetamol for their little pains as well as soap, sunglasses, and our regular giveaways. Thankfully, all of the turning-people-away was done by the admin table and not myself, but I can imagine having to be the one to do that is hard. Some confusion regarding our criteria for inclusion between the staff led to more frustration, as some were turned away who maybe shouldn’t have been or vice versa. Either way, the morning and resulting tension stands as a testament to the age old lesson learned by junior doctors everywhere: You can’t help everyone.
Sometimes you have to decide who gets help and who doesnt. It’s not a fun exercise. This is particularly topical in the age of Covid that has brought so many discussions, particularly around the triage of ventilators, to the dinner table of people who had never had a reason to contemplate it before. Broadly speaking there are two main principles that govern triage of medical resources, acuity and probability of treatment success. If you have something really serious, you should get seen sooner than something not serious. Also, if you have a good chance of surviving if we intervene now, you should be seen sooner than someone whose chance of surviving is already very low, this may sound paradoxical, but consider that acting now maximises your probability of successfully intervening in the patient who has a good shot. If you treat someone who is likely going to die anyway first, you raise the probability that both interventions will fail as you burn time that could have been used to intervene successfully in another patient. Broadly speaking those two concepts influence most of the decision making, although the finer points relating to age, quality of life after treatment, and cost of interventions muddy the waters and lead to all kinds of philosophical and numerical discussions about what is the best way to triage care. The point I am trying to make is that it’s not easy and not simple, even when it seems so.
On my way into clinic, before we had seen a single patient, a woman stopped me walking on the path, probably in her late thirties. She told me that she knew we weren’t going to be seeing everybody, but that her mother was sick. I asked her what was going on.
‘A fever’ she told me.
‘How long?’ I asked.
‘Three days… She is not eating. You will have to come to the house as she is very weak.’ She said
‘We’ll put her on the list’
That information, should it be accurate, is definite cause for concern. However, people don’t often have thermometers here, and more that once patients have told me they were flying with fever because they just felt unwell and I take their temperature in clinic to find it totally normal. Also, when people tell you they aren’t eating, I tend to become real pedantic. Not eating means you actually have not eaten, not that you don’t want to eat, or have been eating soup, or eating less than usual, which is 8 times out of ten what they actually mean. Either way, dramatized or not, that is not the kind of patient you can turn away even if we are only here to see the chronic patients. We put her on the list for home visit at the end of the day.
After spending the better part of six hours modifying patients’ blood pressure medications and chatting about sore backs, we wrapped up clinic in the rancho and moved on to our house visits. There were two; one was a chronic patient with mobility issues and our woman with a fever.
The first gentleman was young, in his forties, and he had suffered an accident many years prior. He was a paraplegic now and couldn’t walk. We spoke briefly about his medications, he was taking amitriptyline, a very powerful tricyclic antidepressant, which is also used to treat neuropathic pain. He was remarkably charming and well humoured. His indwelling catheter was changed once a month in Bocas town. It’s important to change catheters monthly because they become so easily infected when they are left in. The last thing you want in a paraplegic is a big old infected bladder tracking up into the kidneys, which can be a recipe for disaster. After checking his catheter I did a neurological exam on him, upper and lower limbs. There was no good clinical reason for doing it than my own curiosity, his condition was well documented and he had been known to us for years. More than anything, I just wanted to try my hand at explaining the neurological tests and seeing how he responded. It can be really frustrating to do exams on people sometimes because they just can’t follow what you want. The neuro exam in particular drives me mad, often unfolding like so:
‘I am going to touch your arms and legs. Every time you feel me touching you, please say yes out loud so that I can hear you. You need to say it out loud though because I will be looking down. If you nod, I won’t see it. Got it?
‘Got it’
I touch their arm and they say nothing.
‘I need you to say yes out loud so that I know you can feel me. Okay? Let’s try again’
Again I touch their arm. Again they make no sound
‘Can you feel me touching you?’
‘Yes’
‘Great. Now I need you to say yes out loud every time I touch you. Touch, yes, touch, yes. Okay?
‘Okay’
I touch them on the right arm and they say yes, then I touch them on the left arm and they say nothing.
‘Every time I touch you, I need you to say yes. I need to hear you because I am looking down.’ Am I beginning to sound like a broken record? Usually at this point it breaks through
I touch the right arm, yes, left arm, yes, left wrist, right wrist, fingers, yes, yes, yes.
‘Okay. Now… Tell me, did it feel the same or different on both sides?’
‘Yes’
‘Sorry I am asking something different now. On both sides, the right and the left, did it feel the same when I touched? Or different?’
‘Yes’
‘Okay then’
This of course is always completely my fault. I am working on finding the perfect combination of words to convey the info with no confusion. Remains a work in progress.
My fascinations with the clinical exam had me spending a little too much time with this patient, and we were under pressure to get going. Our last patient still had to be seen. We split our efforts, as the captain and one staff member loaded the boat, I went with the clinic manager to see the patient. I had to climb up a hill and crawl through a gap in a barbed wire cattle fence to get there. The patients daughter made it seem so effortless in one smooth motion. Shrek moved very gingerly and did it in twice as long. Another sharp hill brought me up into the house, which had me climb up the flight of stairs onto the wooden beams. The mother, aged 56, was sitting in an outside room, like a veranda that overlooked the entire community. She looked distressed, and her coarse black hair was painted on her forehead from sweat.
I sat down with her and we started talking. She told me for three days she had a fever. She was also quite nauseated, with a headache, and had eaten very little. That was the entirety of her chief complaint. She wanted medicine. I told her I would just need to talk with her for a while first and then we could decide what was best together.
I began going through my standard infection questions. She had no cough, some shortness of breath with walking, although she was 56 and slightly plump, and considering she lived at the top of this huge hill it seemed pretty reasonable. No stomach pains, no diarrhea, one episode of vomiting three days ago no difficulty urinating, no unusual skin marks or rashes. It could have been any number of things, although some kind of gastritis was at the top of my list. Then I remembered where I was, and asked if there was any discharge down below. She told me yes. Then the daughter came in.
‘I am really worried about her. She is very weak.’ She told me.
‘I am looking into that’ I said. ‘She definitely has a fever.’ Her temperature had read at 38.4, which is well above my threshold for fever at 38 degrees.
‘Has she been in hospital for anything like this before?’ I asked.
‘Last year she was in hospital. She was bleeding from her vagina and went to hospital. The gynecologists did something to her. They hurt her and so she didn’t want to return. She was told she had to go to Panama City.’ Her daughter said. ‘Last night she didn’t sleep with the fever, and had been taking herbal remedies but—‘
‘Hold on. What?’ I said doing a bad job at hiding my discombobulation. ‘Sorry, wait. Let’s go back to this about hospital. When was that?’
My history taking had been hijacked. I didn’t care anymore about how she felt. Panama City is serious business. I had to know everything. The story she painted was dark. Really dark. I knew almost right away her mother was in the process of dying right in front of us.
At age 54, she finished menopause. For one year she had no bleeding, adapting to post-menstrual life. Then the blood came back, and it came back with a vengeance. She started bleeding a lot, with clots daily. This was one year ago. Post-menopausal bleeding is endometrial cancer until proven otherwise, that’s what I had always been taught; it has to be investigated immediately, with urgency. Her mother thought it wasn’t anything weird at first, but then it didn’t stop, and she went to Bocas hospital. That’s where something happened, and from my own dealings with that hospital I know they don’t have vaginal instrumentation, which is to say they cannot do any interventions like surgery or dilatations curettage (a little vacuum that clears out tissue after something like a miscarriage). This lady probably had a vaginal ultrasound, which is done by inserting an ultrasound probe into the vagina which gives you a better look inside than through the wall of the abdomen. She didn’t like it. She felt violated, which she was in every right to feel, and so she buried it all and never followed up. They had been told that samples were sent to a lab, given a number to call and a place to go to follow it up, and that treatment options likely would bring them to Panama City. They never did, and she sought herbal remedies instead, which worked a little bit at first, until they didn’t. This woman had cancer, clear as day. If they could tell from the ultrasound that Panama was the likely option, it meant the thickness of the endometrium was already larger than 4mm, which is nearly grounds to make a provisional diagnosis, although samples are always sent to be sure. Now she’s had cancer completely untreated, and been losing blood for a full year. I tested her hemoglobin and it was 7.4, meaning she was severely anemic. In America, anything below eight is bad enough to get a blood transfusion.
The thing about cancer is that it grows so uncontrollably it abandons all rules of cell maintenance. Cells grow and reproduce with completely abhorrent morphology, like millions of little Frankensteins. They grow at such a rate that they outgrow their own blood supply, and begin to choke themselves of oxygen until they die. For that reason cancer cells produce large amounts of growth factors that increase blood vessel development, and those arteries themselves can grow with demented features, like leaky walls that make infiltration of cancer into the bloodstream easier. She had been leaking blood for months and months. Her infection now was likely a function of necrotic cancer tissue in her uterus becoming fodder for bacteria. It was the straw that broke the camel’s back. If it weren’t for covid, one of our clinics might have caught this and inspired urgency from them sooner, or if she had a decent enough relationship with the gynecologist in the first place to understand the gravity of the situation despite her discomfort. Now we were on thin ice. She had to go to hospital right now for her anemia complicated by systemic infection, although her cancer was potentially too far gone.
I called the boss, just to ask for his advice. He was on board with my plan form the first moment I presented the history. I told him that I wasn’t even going to bother with a vaginal exam, because it wasn’t going to change what I would do. She still had to go to hospital, and this time we couldn’t be denied because we had her hemoglobin values as proof. I recalled our previous experience, just a week ago with the patient who was discharged that very night and then got worse and wound up in Changuinola, and I said something to Dr LaBrot that I was worried might make me sound like a sicko.
‘Doc in any other circumstance, I would give a gram of paracetamol to make her feel better’ I said. ‘I know this sounds twisted, but I think I am going to hold it. I think she needs to get to hospital with a fever, as sick as she is now. What do you think?’
I heard silence on the other end of the line. I’ve really done it now, I thought. Thankfully the signal just cut out. He agreed.
Now came the difficult part; she was so distrusting of the medical system that she’d been tolerating vaginal bleeding for almost a year, so how would I convince her to come to hospital with me right now? I sat down with both her and her daughter.
‘Listen, I am going to be frank with both of you. I am worried’ I said.
‘I know doctor, I am worried too’ answered the daughter
‘I understand that right now, your biggest concern is the fever’ I said to the patient ‘I am worried about the fever as well, but that is not my biggest concern. Remind me how long you have been bleeding for, recount exactly’ I already knew the answer to this, as I had listened very carefully before, but I wanted to give her a chance to speak, to become an agent in our conversation instead of just listening to me talk at her.
‘In the summer… then August, September, October, November. Then it stopped for a bit, and came back in late December.’ She said
‘That’s when the discharge began coming as well right? On an off?’ I prompted
‘Yes’
‘Okay. You have been bleeding for a long time. Your blood is very weak, you have lost a lot. I think this infection is only the final drop in the bucket. I can give you medicines now if that is your wish, but we need to go to hospital. I want to go right now, we have a boat and you can come with us. I know your last experience was unpleasant and I cannot speak to that. Would you be willing to come to hospital if I speak to the doctors and tell them myself that you don’t want to have anything introduced down below. Would that be a potential solution?’
I let my words sit with her. She was a tremendously stoic woman, although her blood saturations were low and her heart rate was elevated to compensate for the poor oxygen carrying capacity of her blood. I can imagine how strongly she must have felt one year ago about her refusal to return to Bocas, but now she had been at the herbal methods for long enough, or perhaps just no longer held the energy to put up a fight. She agreed to come on those terms mentioned, and I gave her my word that I would do everything to prevent her going through another traumatic experience.
A miscommunication within management brought me some unwelcome news as I was finishing my conversation with the patient. The captain had been given word to leave for base without us, and we were to find auxiliary transport into Bocas town for us and the patient. Thankfully Jack was still on site with me, so that became a headache for him to deal with while I finished documenting everything on the patient chart and our woman got herself ready.
Now, what happened next was a learning point, a valuable lesson for me on that purgatory that exists between unwell and decompensating. As I waited with my things down by the barbed wire fence, I saw our patient come out with her family members in tow. Wearing a headdress to fight off the heat, and aided by a long bamboo stick, she slowly floated down a fairly steep hill before coming to a kind of trench dug beneath the fence which she used to come out on the others side, flanked by daughers. I waited for her, stethoscope around my neck and looking somber. We walked slowly in silence towards the dock, more and more of her family members appeared out of various shacks as we walked with leaden steps, her setting the pace. She had walked about 60 metres on the horizontal before she came slowly to a stop to catch her breath. She stood there in silence, staring out into the fields. She slipped off one croc, then the other, and her grip tightened on the bamboo stick, pressing it hard into the dirt. We all held our breath. An eerie sensation came over me. I hadn’t even considered that she likely hadn’t moved farther than ten feet at once in god knows how long, and I just made her walk 60 metres with a hemoglobin of 7.4.
‘Oh no’, I thought to myself. ‘She’s going to crash.’
