Unfortunately for everyone, it rained torrentially through the night. With the rain came a sweeping wind that tickled the tush in all our hammocks, and in the morning you could see poor sleep clearly in many people’s eyes. Not ideal, but hey.

I’ve done more with less.

After breakfast around 7:30, people were already lining up at the front of the rancho. Patients on our ‘chronic list’ would be the first to guarantee appointments with a physician – everyone else would be given a number and sent to the so called ‘triage’ station, that would take patients one at a time and determine whether their complaints could be quickly dealt with (things like, say, indolent sniffles, blood pressure or blood sugar screening, eyedrops for dry eyes, reading glasses, or otherwise). Anything minor was taken care of then and there by the triage provider, and those with something warranting a real visit with record keeping were sent back to the admin table to get formal intake and registration. I was a big fan of this faux ‘triage’ service, as it provided the opportunity to get through more patients with less hassle from my timeless enemy: the electronic chart.

Electronic charts, despite being an obvious progression from the imperfections of paper documentation, have been a perennial headache of mine since I started residency in the United States. Paper charts certainly have obvious their deficits: Some doctors (if not most), have brutally awful handwriting. Not to mention the existence of a physical chart also means that sometimes you’d come around looking for one and be unable to find it – I remember dozens of occasions on attachment in Ireland, hovering around the nurses’ desk looking over everyone’s shoulder trying to get a hold of bed 21. Despite this, the documentation itself was simple. You wrote a daily note with the relevant points and moved on. If nothing changed in the plan, a small note might say ‘carry on with current regimen.’ Life was easy, uncomplicated. Electronic charts are another beast entirely.

Endless data points and sophisticated software can take you halfway around the world before you actually find the small bit of information you might be looking for. Patient notes grow longer as segments are auto-imported from elsewhere by pre-made templates with pages and pages of cluttered space. Since the notes are the primary billable points for the hospital, the onus winds up falling more on the documentation than the actual care. The end product is a system in which physicians, especially young overwhelmed trainees, are encouraged to prioritise their note-writing, and patients wind up existing more inside the computers than they do in their actual beds. I can’t stand it. I worry that with the introduction of electronic charts here at FD that we may begin to fall prey to the same pitfalls, which ultimately place more distance between us and our patients.

Thankfully however, the chart system they implemented was quite easy to use and straightforward. Some headaches still existed of course, on several occasions I found myself frustrated at the need to scroll and click through diagnosis codes for minutes and minutes when all I wanted to say was that I continued the patient on her diabetes medications. On the flipside though, seeing patients, I could now click directly into their previous visits and find out fairly quickly what they had been seen for and all the things that had been done in the past. For all my grumbling, it certainly contributed to more continuous care across visits and made things better. Technology 1 Juan 0.

I saw chronic patients that day with James one of the kiwi medical students, and his presence helped to streamline our visits as we’d see patients together before I stepped aside to do documentation and he started the next. Many of our patients that day were repeats of things I’ve already written about extensively; blood pressure, diabetes, men with pain related to manual labour and children with cold and flu symptoms that hardly worried me. I remember after the fourth or fifth kid coming in with the same complaint of diarrhoea, congestion, and fevers at home, I turned to James.

‘James, remember what we talked about. Are you worried about this kid?’ As I spoke, the little girl in front of us, clearly congested, ogled with curious eyes as she reached out for my stethoscope.

‘Not really,’ he said.

‘Why not?’ I asked. ‘Mom is telling you she’s had diarrhoea at home and at the moment she’s running a fever.’ I was testing him the same way one of my own instructors had done to me when I was on an attachment down in Wexford town in the south of Ireland. I remember she was an older woman, a seasoned general practitioner, who had a knack for common sense medicine.

‘Well,’ he said, speaking up as he brought his eyes up to meet mine. ‘Mum says she’s eating, and she looks okay. Also it sounds like her symptoms are getting better and she’s over the worst of it. As long as she’s playing and not flopping like a dead fish I have no concerns.’

‘Bingo,’ I answered. The teaching cycle comes full circle. Nearly poetic.

Clinic wrapped up around 4pm, giving some of us the chance to float around the community and entertain ourselves before dinner. Many went to the river, but myself, and Cristobal went down to the school accompanied by Elvis, one of our Ngӓberi helpers who was joining for the week of clinics. At the school we found an asphalt volleyball court and a game in progress, and made ourselves available to join in. With the exception of us three in our mid-twenties, the kids playing probably ranged anywhere from 11 years old to 16, and my goodness did they bring the thunder. This was no North American everybody-gets-a-turn rinky-dink street game. This was king’s court as the same team of a few lads and a girl brought the hammer down repeatedly and won 10 straight until it got too dark to play. By the time we wrapped up I was late for dinner. A bath in the river after dark was followed by another session with Fermin, the ukulele, and anyone who wanted to join in. I learned Elvis, befitting his name, actually has a great singing voice.

The next day I was given the chance to be the ‘triage’ clinic provider, which was a nice change of pace. I bid farewell to my medical student as he was reassigned to Shane, and got down to it. The morning itself was fairly ho-hum until I saw a patient close to lunchtime. He was a gentleman in his thirties who was complaining of chest pain when he walked around.

As a general rule in medicine, chest pain is a complaint that you have to always take seriously. Sometimes it’s difficult to parse out what patients describe as true ‘pain’ versus ‘discomfort’, ‘pressure’, or ‘some sort of sensation’. This is because unlike your limbs, bones, and muscles, the nerve receptors for pain distributed to the internal organs are far worse at localising pain. I’ve seen patients who just complained of shortness of breath, new ankle swelling, or even abdominal pain and wound up being diagnosed with a heart attack. Usually, I open up with the most open-ended question I can ask, and this puts my cart on a path in some direction.

‘Tell me more about this pain,’ I said.

‘Well,’ he answered, as he pointed to the lower end of his sternum. ‘It’s here. It doesn’t usually bother me, except for when I am walking or doing exercise, then it comes on. I have been here to see the doctors before about it.’

‘What does it feel like?’ I asked.

‘What do you mean?’ he said. This is a common response.

‘For example, does it feel sharp? Stabbing? Burning? Squeezing? Pressure?’

‘Pressure.’

And off we go. Very quickly I was able to discern a few key elements that raised my suspicion. Chest pain with exertion is typically a sign that the pain could be heart related, as the cardiac muscles work harder to compensate for the increased blood demand of tissues during exercise. Also, pressure-type non-specific chest pain is more likely to be cardiac in nature than stabbing or sharp pains. I had a Cardiologist instructor of mine once tell me something I still use with my patients to this day.

‘If you can point at it decisively with a finger and tell me exactly where it is, it’s not your heart, plain and simple.’

As I started to think about my differential, I had to put the brakes on all of it. My job here was triage, and this gentleman was going to need a real visit with charts, vital signs, and the rest. Unfortunately, my job with him ended here. It’s always unsatisfying not being able to do the job from start to finish, and this is why despite my love for emergency medicine I just couldn’t commit to doing it as a specialty. I told him that we’d have to register him and then gave him a slip of paper to take to the admin desk. He was seen later by one of my colleagues and we actually discussed the case later that week. It turns out our friend had a 5 inch nail bolted into his sternum in a workplace accident several years prior, and now lives with an ugly chest deformity square in the middle of his chest. It would have probably been useful information for me to have right out of the gate, but hey, life doesn’t always give you exactly what you want.

I continued to triage patients throughout the day, with few truly novel or interesting cases coming my way. I got to chit-chat a lot with the patients as things started to wind down in the afternoon which is always nice. I also found myself getting distracted several times, as sound emanated from a nearby house with a power line and TV. It was World Cup season in Qatar, and like it always does, the world’s game was reaching every corner of the globe, including the Ngäbe communities here on the mainland. This particular game was a cracker with a lot of goals, Portugal’s 6-1 drubbing of Switzerland in the second round. Every time the ball found the net, children would shout as the calls of ‘Goooooal!’ would radiate through the whole village. I would be lying if I said I didn’t pop my head in a few times between patients.

After clinic, again I wandered toward the volleyball court, this time seeking redemption. Something different was happening today though. As we played, hammers and saws took apart the nearby structure next to the court and made way for a huge metal beam reaching around ten metres in the air. Nearly a dozen men then brought over construction materials and a sound system of clunky speakers. I found out fairly quickly what was going on – that night, the community would be celebrating the construction of its first ever community Christmas tree with lights and a big star at the top. One of the construction fellas, unclear what leadership role he held if any, got on the microphone and started bantering a play by play of the construction, complete with shout-outs to the volleyball game gringos (me), his wishes for Argentina to hoist the trophy (vamos campeon!), and several other disjointed but entertaining ramblings. Clearly he was having a good time.

That night, right around 7, the whole community came out to celebrate the lighting of the Christmas tree. Loads of people, young and old, lined the concrete path and the volleyball court. The man on the mic was back now too, followed by the church leader who said some words about the project and thanked all the groups involved in its genesis. This was followed by some prayers, and then a ceremonial lighting of candles. We were tremendously honoured as a group as they asked us to light the wicks as a sign of their appreciation for our care. When the tree was finally lit, it was a spectacle to behold in all its glowing beauty. It was heartwarming.

The more I thought about it, the more this togetherness made sense to me. All the houses that line the community are metres apart from one another. Voices carry through from home to home all day long, dogs may have owners but they roam freely, and children walk to school a stones’ throw down the street. Even if you wanted to, you simply couldn’t get away from your neighbours if you tried. This, complemented by their shared tribulations, forms a tight-knit community of people who depend on one another. To be honest, I was taken aback by the intimacy of it all. Children, parents, the church organisers, and the rest all blended into one living, breathing collective just enjoying the company and camaraderie of creating something beautiful together.

Watching it all, I thought about how ceremonies like these, community projects in which everyone comes together, are found few and far between in the communities where I grew up. I got to know just one or two of my neighbours in the suburbs outside Toronto. Everyone just gets in their own car, drives to work, takes their kids to school, and tries to live un-disturbed it seems. The government winds up becoming the only source of community affairs, maybe by organising a fair or festival, but seldom does that actually come from the community itself. Why is that? Is it because technology makes it easier for us to do things without leaving the home? Is it because we no longer actually need the support from our neighbours to live fruitfully? Is it because the state gives us so much, that the onus no longer falls on us to create or cherish things together? I don’t know, but what I do know is that I thought about Philadelphia, a city that is so clearly hurting in so many ways, where despite so much wealth, so many are neglected and fall through the cracks. I thought about how despite endless attempts to build relationships with the people that live in my own building, I feel like everyone is content to just mind their own business.

I thought about how we have so much to learn from communities like Norteño. Despite their seemingly worse metrics for inequality, I’d wager everything on many of them actually living more enriched and meaningful lives here than in the Occidental West. What does that mean about the nature of inequality? What is inequality really? Financial inequality is easy to measure, to understand, but what about inequality of community, or inequality of meaningful connection? As I think about what it means to build health, I realise that maybe I have been looking at health the wrong way. Is health really just health? Maybe health is community. As a humanitarian, I feel like if I had to choose between building community or building health for people in need, it would be a no brainer, I’d choose community every time. Community is our reason for living; without that, there is no point in health at all. Some would maybe argue that these responsibilities lie in different structures, after all, doctors have their hands full with the medicine already to be concerned about building community. But then I ask myself, why the hell not? As I ponder my future in humanitarian medicine, I start to think that the real opportunities for change may come farther outside the realm of traditional ‘health’ than I once thought. A strong community will produce good health, as people strive to take care of one another and hold each other accountable. All the accurate blood pressures and blood sugars in the world will never give you that.

So under the sparkling lights of this glowing tree, and under the shining stars of our beautiful universe, I sat and contemplated these things. I took my ruminations with me to the river, where Elvis, Cristobal and I bathed and talked about life under the full moon. I think something clicked inside me that I can’t undo. I know it will be hard to take these conclusions back to my place of work in America, to a system that obsesses over metrics and pigeon-holes the best of us into becoming box tickers. Maybe, for the right patients, I can worry less about medication adherence or healthcare metrics and invest my time in building meaning through personal connection. Maybe in the future when I approach medicine at a population level in the field of humanitarian action, I will think harder about community building and education as the real goal before the nitty gritty of preventative medicine and healthcare outcomes. I am not sure. We can only work within the systems we live in, but that’s okay.

I am taking notes.