I stepped off the concrete path into the dirt in front of her, and gestured for her to sit down. We needed a wheelchair, fast. Somebody, a nephew, was sent off to source one in the community. With the help of a few, we lowered her onto the ground and I reached out to grab her wrist. Her heart rate was flying, easily 150+, and her breathing was short and choppy, close to 60 per minute. The colour was draining from her face, and I could feel her dissolving. Within the family around me, emotions began to run high. ‘If she is so sick, why was she walking in the first place?’ One said. ‘She wanted to walk herself’ said another ‘That was the last of her strength used to get here’ ‘You know how she is’. All of the voices blended into one as discussions broke out. It was the sound of a worried family, and I felt for them. We were now a big group, upwards of ten, and this was a family watching their matriarch crumble to pieces in front of them. The woman who fed them, gave them shelter, and molded them into adults was dying. I kept my opinions to myself, letting them air it out as a family and I continued to count breaths in silence. They were only getting quicker, and her eyes lost some of their luster, she was now almost unreachable by my words and gestures, floating on the edge of consciousness. She was such a hardened woman that she didn’t actually faint, keeping herself awake, although it might have made things easier if she had.
Finally a wheelchair arrived, and without any strength in her legs to help us get her off the ground, raising her up proved harder task than first envisioned. We had to put her down after our first try and go for it again, and her stoicism could no longer hold. She cried out when we got her on the wheelchair. Her sounds cut through our ethos like a knife, and pushed her family into pandemonium. In a flash, tension turned to panic, as if we had been a group of soldiers waiting for an ambush that finally leaped out from the bushes. The last two hundred metres to the dock was difficult to watch, as her many kin desperately worked to fan her with towels and provide some solace. I considered whether this might be the last time her family saw her, and it was hard to digest that this could be their final memory of her.
Furthermore, to make matters worse, the only other boat available to take us into town was away in Almirante with other clients. The dock was cut into jungle that dangled above alongside a little canal for a stretch until the bay itself. Tide was low, nearly at its lowest, meaning that the several boats tied to the dock in front of us couldn’t even sail out of the island since the shallows were so risky. Jack and the family dialed numbers and ran to houses trying to find some way to move her with very little progress. By this time it was already getting dark, and we were losing time. One of the nephews had enough of waiting, and he jumped down into his own boat which was stuck in the dock by low tide and began bailing out water with a cut-off plastic bottle. Trying to make myself useful I jumped down with him.
‘Need a hand?’ I said
‘Please’
For the next twenty minutes, time ticked as the family sat nervously with our patient tending to her every bead of sweat. Thankfully, she stabilized. Meanwhile myself and the nephew bailed cup after cupful of water without a word. Finally we felt ourselves rise off the floor, and another ten minutes of strategic paddling and pushing off the ground to fully dislodge us allowed us to angle towards the dock. The boat didn’t even have a motor, so one had to be put on board and fixed first, I have no idea where it came from, if it was borrowed, loaned, or rented. Between a group of 6 of us, we locked the wheels on the wheelchair and place our lady square into the middle of the boat. I had to put on my headlamp because the sun had now gone down. We rumbled out from the dock, myself, Jack, the patient, her daughter, with the nephew at the controls, and began our journey across the bay to Bocas. The rest of the family watched us become a shroud that could be only heard and not seen after 30 seconds.
I used my headlamp to give us some visibility for other boats in the black of night. Our motor was smaller than the standard 60 horsepower propellers, sitting at 15 horses. We moved slowly, and things were going well for about twenty minutes until I heard a cry from our patient’s daughter.
‘El motor!’ She said ‘The engine! Lift it up, we are in the shallows!’
I poked my head over board, angling my headlamp down. She was right. We had gone too wide from the buoy that marked the passage through the bay, and were now sitting centimetres from a coral reef in low tide. The engine cut down into its lowest gear, and we floated tensely for a moment. Either side of the boat I heard whizzing along the water, like little bullets. They thundered next to the boat, skipping on the surface of the ocean like they’d been shot out of a pistol. Anselmo later told me later these were called Agujeta fish, Hemiramphus saltator, who responded to being startled at night by launching themselves at high speed out of the water. They have pointed ends like little spears, he told me, and should you have the bad fortune to catch one to the chest at high speed it could be game over. I was hearing them in surround sound; a few sounded like they passed only metres from the boat. We floated out of the shallows with nothing but patience, and made it to shore where an ambulance was already waiting for us arranged by our patient’s son who lived in Bocas town and met us there. The ambulance was just a converted van with a stretcher in the back. There was only a driver, no paramedic. The four of us got into the back with our patient, who was now somewhat alert, just exhausted.
Arriving at hospital was similar to my previous experience, at the door I was treated with utmost respect. I announced to them who I was, and they were keen to listen to what I had to say. The triage nurse took our patient’s temperature and low and behold, her fever was now gone. Great. Also, likely by virtue of her being immobilized and not speaking a word for close to an hour during our transport, her saturations were picture perfect. I felt a little stupid telling her that she had saturations of 88 and a fever of 38.4 two hours earlier. The triage nurse nodding her head as if to say ‘Sure hun, I believe you’, and I can’t blame her. Thankfully I knew I had a trump card. Her history and her hemoglobin could not be ignored. Once the emergency doctor on call saw her, she came outside and asked me for the story. I gave it to her cut and dry, she agree that something was going on that had to be investigated. Then she hit me with a curveball.
‘What do you make of her abdominal mass?’ She asked. In my fervor I hadn’t even bothered to examen her, and now I was getting called out for not knowing the first rule of patient handover: know the freaking patient.
That makes two learning points from this case
- Don’t kill your patient by making them decompensate walking sixty metres when they are deathly anemic
- Do a clinical exam
Feel like I should know those by now. Talk about feeling stupid.
‘She has an abdominal mass?’ Answered Dr Bozo, hiding his embarrassment under his PPE.
‘Yes. A significant one. We will have to do imaging. She will spend the night here for sure and likely go out in the morning for Changuinola to have that done. It might be best for someone in her family to come back in the morning and we can sort everything out.’ The doctor said.
It all sounded swell to me. Our job was done. Jack updated everything on our group chat and a wave of cyber congratulations bolstered my ego. Dr Bozo burst from his cocoon fully formed into Captain Ahab, who for the second time in two weeks scaled the high seas with a critically ill patient on board in treacherous waters. We got a lift into town with a ministry of health truck, and Jack and I rewarded ourselves with some fried chicken and plantain from a roadside stop on our way back to where we had docked. We even had a beer and enjoyed some enjoyable conversation with the patient’s daughter and her brother. On the boat ride back I was amazed at how beautiful the night sky was. I looked up at it for so long the next morning I had a kink in my neck.
All in a day’s work I guess.
Things were about to change though. The next day, I would be stepping down from my position as acting lead into my actual role of elective student. Dr Solleveld was finally out of isolation and chomping at the bit to get started as the chief. I had already gotten to know her over the last two weeks, and our attitudes in many ways couldn’t be more different. We were the same age, although she was already in her third year as a working physician, with two years of hospital medicine and a Dutch education. She was structured, detail oriented, smart as hell, and committed to the exactitude of numbers. She wanted references, Z-scores, conversion charts, and all those tools that I didn’t even realize existed. Where I was happy to just give it a go with something that made sense, she did things right, by the book. If I was a cowboy, she was a sheriff. I was excited to learn from her, although I’ll be honest that I wasn’t sure how she would integrate into the chaos that was our mobile clinic. Only time would tell, and tomorrow would be her first day.
The Doctor was finally here.
