The morning of our first day clinic started out fairly similar to how I remember, just with more people. Breakfast was followed by packing, and with many hands making light work we motored out against cloudy skies to a community by the name of Sharkhole. Despite only getting the chance to see part of the full roster when I was here in 2021, the communities we’d be visiting throughout my month here were all ones I had seen before. I remembered Sharkhole in particular because it was the village where I had seen a young gentleman who arrived at the clinic in asphyxiating heat wearing huge galoshes and coarse denim pants after having been bitten by a snake. I imagine he learned his lesson. 

Unloading at the clinic was an easy enough task, and with multiple providers this time around things were set up quite differently. We had two provider stations, consisting of plastic chairs and an exam bed, which would function simultaneously. The physicians seeing patients would be myself and Bernardita, or Ber, a young blonde Argentinien doctor with a sharp smile who loved to chat. We’d also have the support of the two medical students shadowing us at each station. Patient’s would arrive and register at the admin table, with their identifying details placed into a patient encounter on one of the many tablets before being designated a physician consult line (myself and Ber), a physiotherapy line run by our physio, or a low acuity ‘in and out’ station speared by another one of the doctors for trivial matters like runny noses or simple consults that didn’t warrant the hassle of full registration and formal intake. While all these stations were humming in unison, one of the staff physicians designated the ‘Lead Medic’ would provide oversight and essentially float between all the stations as technical concerns arose.

Immediately, so many of the cases I remember seeing seemed to reappear one after another. The patients with poorly controlled blood sugars who had run out of their medications, the mothers of 8 or 9 children, all of whom suffered from the same fevers and upper respiratory type symptoms, the dehydration headaches, and the men and women with endless musculoskeletal ailments from living through the day-to-day of manual labour. By mid-morning it almost felt like I had never even left, with one very notable exception – I had to ask for help finding the right medicines in the pelican bags.

When I was here on my first attachment, I packed the pelicans myself. I also packed the giveaways like glasses, vitamins, fortified rice, and other medical equipment. I had a steady finger on the pulse of all the things we had and didn’t have. I knew exactly what I could offer. It was frustrating having to ask my Dutch Lead Medic time and time again what pelican stored the oral paracetamol solution, the anti-fungal suppositories, or even basic gear like glucometers and pulse oximeters. It seems trivial, but having to ask for help so often after joining a team that welcomed me as an auxiliary volunteer and not as a true staff member just gave me a slightly stronger drive to prove myself to the other physicians. It seems kind of mental in retrospect, that it bothered me so much to be exactly what I signed up to be – a volunteer physician. I suppose the constant overhanging imposter syndrome and self-doubt finds different ways to manifest itself at every step of our journey as professionals. It was like I swapped the desire to prove something to myself in exchange for proving something to those around me. I have to also recognize that it probably would feel a bit abrasive to the existing staff physicians, who had been here for nearly a year now, for a guy like me to show up as a volunteer on a four week agreement and expect to be treated differently than other physician volunteers. I felt different, sure, and maybe I was by virtue of living a completely unique experience here the way I did, but I had to respect my role. This was something that stung a little bit more than I thought it would. An opportunity for growth I suppose.

Speaking of growth, it was so lovely to function as a teacher with the medical students. Both of them were brutally early in their careers, just wrapping up their pre-clinical years with a lot of time spent reading books and writing tests with little to no experience interacting with actual patients yet. They were basically clean slates, and we got to have a lot of fun evaluating patients together. There was one in particular which I think my student Leo will probably never forget until the day he dies.

Our Lead Medic had asked me to go out on a home visit. It was a patient that was part of our chronic patient list at that community. He had a history of diabetes and was previously on Metformin, which is our go-to first line medication for adult onset diabetes. Unfortunately, we had lost touch with him over the last two clinics, and his wife who I saw in the clinic told us he was newly bed bound and was having difficulty walking. Leo and I quickly had a snack before heading out. This patient lived a good ways away by walk, but would actually be reached in a fraction of the time if we went out by boat instead. Hopping onto the Panga, we rumbled up river for no more than 3 or 4 minutes before arriving at a wooden-plank dock at the base of a tall, steep, and muddy hill. Tides had been so rip-roaringly high over the last few days that the whole base of the hill was swamped out with thick, soupy mud. Oh, how I missed that jungle mud. A few logs and wooden posts had been set on the mud itself to provide stable footing, but the ascent up the hill was still treacherous. The constant threat of rain this time of year meant that navigating this hill was hard enough for three able-bodied young men, let alone an older man or woman dealing with mobility issues related to chronic disease. Like many Ngabe houses, this one was suspended onto wooden posts and raised several metres off the ground to mitigate damage from flash floods during the rainy season. After carefully traversing the mucky hill and dumping my feet in the water bucket outside his door, myself and Leo worked our way up into the main room of the casita. 

The room was fairly typical for the houses in these communities. Wooden plank floors with minimal furniture except the odd hammock chair or wood-plank bed. Groups of children scurried curiously in and out of sight to celebrate our entrance, and our attention turned immediately to the middle aged man sitting up slouched over the side of his bed. The first thing I noticed was his left leg, bandaged from toe to knee with cloths of different colours. Despite not exhibiting laboured breathing or signs of acute distress, he looked tired, and had a big belly. I immediately took a knee next to him. Let’s say his name was Al, and he was in his fifties.

‘Hola Mr. Al,’ I said. ‘I am the doctor. I have been told you are not doing well. I see your leg is all bandaged up. How are you doing?’

‘Not so good, doctor,’ he answered. ‘I can’t use my legs.’

‘Tell me more,’ I responded. Even though I wanted to directly ask questions about his leg, I let him decide how to tell his story. I like giving patients the opportunity to be heard. 

He proceeded to tell us of a fairly turbulent last several months for him. He worked in the fields, like so many, and seven months before I met him, he fell into a ditch and hurt his leg. Unable to recount the finer details of his injury (he just told me that he hurt it), the pain was so bad he made his way to a hospital in the nearest city of Changuinola (about two hours by combination of boat and road travel) and found himself the subject of a long, convoluted admission. During his hospital stay, he had several surgeries on the leg, including what I could tell was a skin graft taken from his thigh, something commonly done when clearing necrotic (dead) tissue from an infection or burn. Unfortunately, he didn’t know any details about his stay at all, without so much as a piece of paper to show for it—This was fairly commonly seen as well, and I always found it hard to know where to place my frustration. On the one hand, it’s possible he was treated and discharged with very little attempts to educate him or provide appropriate discharge paperwork or follow up, but on the other hand it’s possible that all of those attempts were made and things were done right and the unfortunate reality of poor healthcare literacy meant that it was destined to get lost regardless. Based on what he told me, at the time of discharge his leg had a long surgical scar that was closed, healing, and worked just as well as any other leg. That was before the swelling came on.

About two months after his discharge, both of his legs started swelling. This began at his ankles, and progressively worked its way up to include his full legs on both sides. The swelling also began extending to his abdomen, causing him significant pain and positional discomfort. The swelling had gotten so bad in his legs that they were heavy, and weak. This came with a difficulty in laying on his back due to the pain, and a profound weakness that ruled his life. He had never experienced anything like this before.

‘It got so bad in my stomach that I couldn’t sleep. From one day to the next, the swelling came and never left. It even opened up the wound on my leg,’ he said. 

One squat down to his legs told a good portion of the story. His wound, now open for several months, looked raw and ugly but was actually healing. (It’s a process we call healing by secondary intention where an injury is left open like a valley without the edges approximated. The healing factors basically grow tissue from the bottom of the valley up the top with deformed and irregular architecture). He had notable markings of surgery all from his calf down to his toes, and a few toes had been amputated. None of that made much sense if all he had was a simple trauma injury. I think he must have had a pretty nasty infection post surgically, or the site where he had his injury was infected by the time he got to hospital. Still, none of this would explain the swelling in his other leg, or any of his other symptoms of weakness and intolerance to laying flat. As we peppered him with more questions, I pressed my thumb and index finger into his legs on either side of his shin bone, starting at his ankles and working our way up. I gestured for Leo to come down to eye level with me. Withdrawing my finger after every push, we watched as I left a series of pitted imprints all the way from his feet up to his belly button. This was a telltale sign of soft tissue fluid accumulation, something that we call pitting edema, and it can happen for a few reasons. Our job was to find out why it was happening to him. Leo, despite his youth, knew this was concerning. Moving on to his lungs, crackles heard with the stethoscope demonstrated fluid accumulation on both sides. As Leo listened to him, I assessed his neck and abdomen, and based on our clinical exam we had a fairly clear indication of what we were looking at. It was something that I got to know very well during my Cardiology attachments in Philadelphia and in Ireland, but hadn’t seen a single case of it while working with the Ngabe. This patient, for reasons unclear, was drowning in fluid from new onset Congestive heart failure.

Congestive heart failure, or CHF, is a clinical manifestation of heart muscle dysfunction. When the pump fails, it struggles to create forward flow through the system. This leads to excess fluid retention in the body’s blood vessels, and you essentially get fluid backup in several places, like the legs and abdomen in the cases of the right side of the heart failing, or fluid backup into the lungs when the left side is the one impaired. When things are bad enough, patients have impaired respiratory function from all the fluid, causing poor oxygen exchange which is sometimes bad enough to require intubation on a ventilator. Additionally, the fluid backup can cause Liver disease, kidney damage, and a litany of other organ dysfunction.  

Congestive heart failure can happen for a variety of reasons, such as an inherent defect in the heart muscle tissue at the cellular level, uncontrolled high blood pressure, a faulty heart valve leading to years of increased strain causing eventual failure, or stiffening of heart walls due to cellular death after a coronary event like a heart attack. In this population, you’d expect the most common cause of heart failure to be from lifelong high blood pressure, something this patient had no history of. The next most common reason is from a valve problem related to untreated bacterial infections of the throat in adolescence, something called rheumatic heart disease. Again, this patient’s valves all sounded crystal clear, reducing the likelihood that it was the reason for his condition. This left us with very little to go off, and quite honestly we had bigger problems than deliberating back and forth why he was sick.  I didn’t have the tools to treat him out here in the community – this guy needed a hospital yesterday. 

The treatment is multi-faceted. First, we aggressively give patients diuretics, medications that make you pee out excess fluid to reduce the congestion that stretches out the heart walls preventing adequate pump function. This has to be done carefully and with close monitoring, as those medications when used aggressively can cause electrolyte disturbances that are potentially fatal. Then, once the fluid balance has been restored, we start additional medications to protect long term heart function and support the other organs impacted by the condition. He was too far gone and was unlikely to respond to oral diuretics, as in the late stages of volume overload the gut wall becomes so swollen there is little absorption of medications. Even if he did, the amount of fluid that had to come off of this guy was likely to total in the dozens of kilograms, and that could only be done safely in a hospital. He needed physiotherapy to get him ambulating, and likely another revision of his leg wound by a surgical team, given the clear difficulty with healing now four months post discharge. My primary responsibility is to do no harm, and attempting these things in the community was a crapshoot. I sat closely with him and his wife and I explained everything. After they had some grasp on the gravity of his deterioration, I got real with them.

‘My friend, I am worried about you,’ I said. ‘I don’t have the tools to treat you here. You cannot walk, you cannot sleep, you were working the fields only seven months ago. We can help to fix this and make you better, but it can only be done in a hospital. What can I do to help us get you to a hospital?’

‘For that, you will have to talk with my senora,’ he said, nudging towards his wife who was sitting on the plank floor next to me. She hadn’t said much but was clearly listening. I could tell she was worried for her husband. 

‘Decime senora¸tell me,’ I said. ‘How can we figure this out.’ 

This was the perennial difficulty of delivering care to populations so isolated. Getting to mainland was just so hard, and costly. If we offered payment and transport for every patient that needed it, FD would shut down in a few months. Unfortunately, transport had to come from them. Some times  were harder than others to convince patients to go. The Ngabe had their ways to make things happen though.

‘We can get a boat, but would need gasoline, which is costly…’ she said, her eyes indicating silent calculations.

‘Let’s do the following in that case. Why don’t you come back to the clinic with me now. I will have you sit down with my administrator. She will be able to offer whatever supports we have. I need to stress the severity of this situation however. I do not think he will die if he doesn’t go to hospital this second, but he has to go this week. If not, his condition will get worse. Let me give you two a minute to discuss all this before we head back to clinic,’ I answered. Leo and I then stepped outside with our other staff member. 

In the time that we spent evaluating the patient, a torrential downpour had swallowed up the area. One look down the hill made me shake my head. It was going to take a near miracle to get this gentleman down a hill like this given he actively couldn’t walk. He’d likely need several family members to band together and drag him down in a hammock. In the end, we took his wife and sat her down with my Lead Medic, who was able to give them travel funds to get him a community boat to the mainland and then a bus to the hospital in the nearest city. We left them with a handful of cash, no new medicines, and nothing more than a promise on their end that they would seek care. In another world I would carry him myself to the place he needed to be, but that just wasn’t feasible. If only things were different.

Returning to clinic, now drenched (Dr. Bozo left his rain jacket back at the clinic despite the clear threat of constant rain), we rendezvoused with the rest of the team. Surprisingly enough, now around 2:30 PM, all the patients had been seen. A far cry from the 9:00 AM to 6:00 PM single day clinics I remembered. Packing up was quick enough with so many hands, and the return to base was calm and cool. 

In the ensuing days I thought more about Al. I wondered if he wound up going to hospital or not, and asked myself if maybe I should have combed my brain harder for other ways to help him. Still, we offered him what we could, and made an effort to give him tools to bypass the obvious barriers between him and the appropriate level of care. Whether or not he gets treated now is up to him. Be that as inherently difficult to swallow as it is, that’s just the reality of practising this type of medicine. You do what you can.

Regardless, it’s hard to be effective if you stop and weep for every tragedy you see out here. I didn’t have much time to think, since the next day we’d sail just around the corner, on the same island of San Cristobal that houses the medical base to Valle Escondido.