The next morning I woke up absolutely miserable from the mosquitos and the chitras. They positively massacred me. I tried to distract myself with making breakfast before sitting out on the dock to read. I got through forty pages of my book, albeit it took me probably twice as long as it should have because of my constant cessation to address whatever part of my body was irritated from an ongoing or previous encounter with a bug. I spent some time trying to reflect on how it was possible that the bugs were that annoying to me. They had me completely miserable. I thought about how I was in the tropics, in such an enjoyable environment with the sun and the water at my doorstep, and yet I was in absolute misery for much of the day, spending every waking second thinking about how much more I would be enjoying myself if I wasn’t desecrated by bites. I can’t imagine I hate bugs more than the next guy, I don’t even mind bugs. I usually let spiders live whenever I find them. They are just trying to make it like you and me, but mosquitos: I’l be damned. For stretches of the morning all I wanted to do was to close myself inside my casita just to be rid of the pricks. Such a shame isn’t it?

After lunch I called my parents, and gave them a proper tour of the base. I was partway through my tour with my parents, this right after lunch, when I saw a fella pull into the dock. The water had actually stopped running the night before so we were expecting someone was going to come by to fix it. I realised immediately this was not the man I was expecting, he told me that he needed a doctor. ‘My little girl has a fever’ he said.

Well.

Of course this is the part where all of my training disappeared out of a hole in the back of my head. Possibly the same hole through which it seemed I had lost my spine as well, if only for a few seconds. I couldn’t do anything for him, I was technically under covid isolation, at least this was my first thought. Anselmo approached from my right, probably thinking he would have to show the man where to fix the water.

                ‘Anselmo, this man’s little daughter has a fever’ I said to him, hoping he would provide me with some idea of what to do

                ‘ Okay what do you want to do?’ he said back to me.

Jeez Anselmo, thanks for nothing. My first thought was obvious, this man needs to go to a doctor.

Turns out that doctor was me.

I took the coward’s way out immediately, and I told him to sit tight and let me call Sam just to make sure. I want to tell you that the reason I was so unwilling to engage in the role of a physician was because of covid and my isolation, but really I just couldn’t wrap my brain around being the person they were coming to see. I called Sam on whatsapp. No answer.

That really helps.

I did what I next thought to be best, and rang Dr LaBrot himself, the biggest cheese in all the land founder and CEO of Floating Doctors, and my personal mentor on my journey to specialize in humanitarian medicine. Thankfully he picked up right away. His voice made me calm, at least having someone that could validate my presence and my actions was all I needed. I told him what was going on and he had questions about the patient, perhaps not realising that I didn’t even have so much as a name to provide details for. He gave me the green light to give them a consult, and so it began. I ran back to my cabin, grabbed my facemask and my notebook, then took a face shield and gloves from the supply closet and went back out to the dock.

He was a young father, possibly younger than myself, and his daughter had cycling fevers over the last eight days. That was as far as I got before the road became bumpy. I realised quickly that although I was a native Spanish speaker, all my professional training was in English, and taking a history without knowing the proper words to use is immensely frustrating. Not to mention that by force of habit I encoded all the information in English on my notepad. It’s hard for monolinguists to appreciate how your thinking is inextricably linked to your language. Without the familiarity of my medical terminology I found it difficult to tie my thoughts together, which is especially important when taking a focused history. Every question is derived from a constantly evolving list of what conditions lie in your differential diagnosis. As a young medical student you just learn a list of things to ask, but you don’t truly become a doctor until you can ask, integrate, appraise, and react all in one fell swoop. This in practice seems easier than it is. Usually when you receive a patient’s history, the information goes right through you from your ears out to the page through your fingertips. Having a logjam in the system at the level of my brain meant that my line of questions was disjointed and choppy. I fumbled over words at every turn. My personality abandoned me, and I became a question asking, phrase-stumbling, unlikable oaf.  

I sat on the dock at a distance as they hashed out the story to me. Four years old. Eight days of high fevers, sometimes up into the forties. She had stopped eating for a period but in the last two days had at least put something down. She had lost weight, they couldn’t quantify how much but only that her clothes fit much baggier than they used to. She had no clear associated symptoms, no diarrhea, cough, urinary changes, vomiting, rashes, lumps or bumps of any kind. Her presentation was entirely non-specific. In pediatrics the most important question is usually the first one asked by a properly concerned grandmother. ‘How does she look to you?’ I asked ‘Is she well?’.

It sounds silly but it’s the god’s honest truth. People don’t just drop dead from one minute to the next, especially not children, when kids really get sick they don’t fight with you. Believe it or not, a child that is crying with all their might and kicking and scratching at you when you try to put an otoscope in their ears is never a child that worries you. When they can barely muster the strength to fight back, that’s when your alarm bells ring. The moral of the story here is that both him and his wife told me that during the day, once she’s had a little tea and some paracetamol to drop her fever, she is up and around like it’s nobody’s business. ‘That’s very good’ I said. The only thing that worried me was how long it had been, eight days of fever is certainly not nothing. I also had next to no understanding of endemic conditions, I thought about helminths, or worms, which are the kind of things you read about in medical school but never actually happen in the occidental world. I considered Tuberculosis, again a condition I knew you had to always consider, but outside of intravenous drug users or HIV positive populations I had never seen a real presentation of TB. What the hell did I know?

I knew I probably shouldn’t have examined her but I did anyway, the gloves I had found in the storage bin were mediums and my hand tore right through the first one as I put it on. Good thing I was smart enough to grab four. She didn’t have swollen tonsils, she didn’t have any lymphadenopathy of the neck. Her stomach was soft, and she was tender to touch in the centre of her abdomen. I felt for feces, sometimes, especially in children, when fecal matter obstructs the GI tract it can form something like a hard ball that you can feel in the belly if you push down hard enough. Nothing. She had a discoloration on the inside of her inner thighs, something completely foreign to me at the time but what I now know to be called pinche blanca, or hipomelanosis en gotitas, a very common eczematous condition that occurs in young girls in the region, its etiology is not understood. Essentially it causes white dots on the skin, almost always below the waste, and it was a benign finding in this little girl. The physical exam gave me nothing of substance to go on. I told them I’d need a minute and that I would consult with the boss.

I rang Dr LaBrot and presented the patient. He agreed with my general impression, a nonspecific fever persisting for that long could be nothing, and so long as the little girl was eating then these things can often just resolve with time. However, a blood test to analyse white cell count and a fecal test for parasites would help to rule in or out anything more concerning and provide some clarity. However, getting a blood test meant boating into the city, which for many of the locals can be costly. ‘Offer them gas for the boat if they need it’ he told me. I had never really thought of that as part of my duty as a physician, but I suppose in this environment a proper understanding of your population forms the basis of your actions. I spoke again with the father, I gave him my impression and explained to him what I advised. Get the bloods done today if you wish, or hold out for a few more days because this may resolve. I gave him a referral letter to take to the hospital, which he was very appreciative of, him and his wife cited to me several occasions were they were turned away without so much as someone laying eyes on their daughter. I can’t speak for the circumstances of those visits, 2020 has made mincemeat of all of us, but I can say that the letter should provide more urgency to their visit. He thanked me for my time and the three of them got in their boat to head away.

And so went my first patient. My first patient that was mine and nobody else’s. I didn’t realize at the time, but that moment was many years in the making. I started with my Grandfather, my father’s father; a public health physician from the Andes Mountains, and malariologist for the WHO who raised his son in Indonesia first and then India. It was a moment fostered by my mother, whose own dad was also a physician who gave up his profession to care for the family business in Buenos Aires. My parents who fled Argentina in the midst of political and familial unrest, and who for so many years thrust perspective on their children by taking them to every corner of the globe while most of their contemporaries traveled as couples, leaving their kids at home. It was a dream born in Argentina, in India, in Africa, and in the far east. It was the beginning of my journey that is still being written. I say all of this in reflection, because in that moment I felt no different. As I watched them sail away I wasn’t really sure what to do with myself next, so I did what any man in my position would do. I grabbed a snorkel and jumped feet first into the ocean.