The next week of clinics would be all about adaptability. We were doing a triple header in the field, two nights of hammocks and mosquito nets into the heart of mountain Cacao country. Nance de Risco, Rio Oeste, and Bajo Cedro would get the circus for one day each. This was extra exciting because the second community we’d be going to, Rio Oeste, was Jack’s home village. His general neuroticism already being magnified by the run in with our ape, he spent the week walking with a wounded leg like a veteran of some glorious combat. Despite his tenderness and flair for the dramatic, I never doubted his durability for a minute, this guy was a trooper. He grew up farming cacao, chopping trees with machetes, and walking barefoot in the mountains. His fitness was impressive, and the guy never wore a raincoat, he would just soak up the tropical rain like a sponge and the walk around wet all day without a word while the rest of us bundled up like we were blasting off into space. Having previously worked in tourism on those very farms, we were now heading onto his turf, and the whole team was excited. Medically speaking however, he was an awful patient, who constantly forgot to take his penicillin after the kinkajou ate his leg for dinner. It also worked to my advantage because if he ever had a moment of sass I could smack him right on the knee where he had his biggest wound.
Taking the boat into Almirante, we were greeted by our driver who drove us up into the mountains through pothole-filled streets. Our clinics were expected to run much better now; with two medics, we could do double the work in the same amount of time. Of course that was all in theory at first, as there is always a period of adjustment.
If there is one thing I learned from working in this setting, it’s that you have to be fluid. In the words of the late Bruce Lee, you have to become water, taking the shape of whatever container you are put in. I feel like this is especially true in medical teams. Medical teams take on the personalities of their leader, and I had a new leader, whose highly structured Dutch approach was novel to me. She wanted to know everything, and before we set foot on any boat she spent the entirety of her isolation period reading through WHO guidelines for malnutrition, consulting treatment algorithms for dozens of different infectious conditions, and using online learning tools to retrain in obstetrics and gynecology. After feeling slightly degraded by her probing questions when she first arrived, I was desperate to show that I was not an idiot. After all, in her eyes I was still just a medical student, a little Bambi whose legs were still shaking after being birthed out onto the floor in a mess of amniotic soup. Actually, better yet: in her eyes I was probably inside the womb still cooking.
With Dr LaBrot, he was a continent away, and although he could be reached at times from some clinics, a lot of my decisions were made in the field by me alone. This gave me some grit and assertiveness in my decisions making, and I functioned with conviction. Having a direct supervisor in the field made me feel smaller, and I found myself falling into a different kind of thinking. I was more doubtful, I wanted to discuss a lot of small things of negligible significance, more than anything I wanted to learn or be reassured that I was doing things right. It’s odd, but it’s almost like I took a step backward. Sometimes I was corrected although most of the time I wasn’t, and our only points of disagreement came in technicalities of referrals or miscommunications due to language.
There was one patient I saw who I suspected had something unusual right away. She came for a birth control injection and instead found out she was pregnant, although she also wanted a consult for some symptoms she was having. Her last menstrual period put her pregnancy at ten weeks and 3 days, so she was nearing the end of her first trimester. She told me that since Christmas, so right around two weeks after her pregnancy allegedly began, she began having intense nausea, abdominal pain and periodic dizziness. As a matter of fact, in the first week of January she had a fainting episode that landed her in hospital, where she was told nothing was wrong. She had never suffered nausea like this before, in any of her previous four pregnancies. A full history of all her symptoms revealed that she had subjective fevers, with a normal temperature in clinic. She also was having some painful urination and increased frequency, and after an awkward back and forth she also told me that she was having some white vaginal discharge over the last four days. I had a list of differentials on my mind. The first among them was pelvic inflammatory disease, at this stage a daily occurrence in my clinic, but I had some more things I wanted to investigate first, like the possibility of an ectopic pregnancy. I got a sample of urine and took her to our private room for an abdominal exam. Her pain was worst in the bottom left quadrant, so starting at the opposite end I worked my way across her abdomen I could feel no palpable uterus at all. I did find something though, something that I wasn’t expecting: she had a mass in her left lower quadrant the size of a lime. It was firm, and sore. It didn’t take much pressing to find it; it must have been pressed right up against her subcutaneous tissue (the fat lying just under the skin). This woman has to go to hospital, I thought. This could be an abscess maybe? A mole pregnancy can also cause wicked nausea like this and a mass. Now to check on this alleged pregnancy…
My Doppler ultrasound registered nothing. Now my understanding of the literature is that the fetal heart can often be heart around 8 weeks with a Doppler, although sometimes not until 12, so there wasn’t a definitive conclusion to be drawn. I also understand that the majority of women with ectopic pregnancies are at highest risk of rupture within the first 48 hours of pain onset, and her pain started five weeks ago and hasn’t gone away. That doesn’t rule anything out, but in my eyes if she was ectopic she should have ruptured by now. All of these factors went into the cauldron of my mind to develop a differential soup, and I debated what more information I needed to rule things in or out. Thinking about Nicole, I figured she would want to see any vaginal exam herself, so I could hold that for now. I told the lady to stay put and presented the case to my new boss.
I went through all her symptoms, her urine dipstick findings, and then layered on the take home message.
‘I think she might have a pelvic inflammatory disease, a pelvic abscess or maybe even a molar pregnancy’ I said.
She was so initially flabbergasted at the extremity of my differentials that she fumbled over her words.
‘Hold on. Look at her urine findings…’ She backtracked ‘You’re right’ she said pausing, trying to find the right words ‘These are on the differential, correct, but we should start with what is common. These things you have here are zebras. She most likely has a UTI. Pelvic inflammatory disease maybe but she has had pain this long with discharge for only four days? It’s not convincing’.
She was right, definitely, but I had my reasons for putting those first on the list. Her Zebra comment refers to the medical adage for medical students ‘When you hear hoofs think of horses not zebras’. It’s another way to say that common things are common, and those are always more likely than the bizarre exotic diseases medical students read about in textbooks. Undoubtedly for me, being told you aren’t getting the picture right can sting, and this was my first time being challenged since I had gotten here. I tried not to get defensive, this was a teaching moment. I answered with my justification.
‘Pelvic inflammatory disease is a daily occurrence here. Also she has a mass. A molar pregnancy can give you a mass and wicked vomiting as well. You’re right though. I figure she probably needs a pelvic exam before we say anything anyways, which I figure you would want to join for as well.’
A part of me wanted to say ‘I’m not an idiot. I know an abdominal mass when I see one.’ But then I remembered that I kind of am an idiot, so it’s fair enough. Regarding Zebras however, I know you’ll never find one in Europe, but in Africa they’re freaking everywhere.
‘I haven’t seen the mass’ she said. Reasonable. ‘Let’s take a look now. Where is she?’
We entered the small plank wood room together to find our patient sitting on our foldable bed, which we had found on base and brought into clinic starting that week. After we settled in, there was startling noise that jarred all of us. It turns out there had been a rooster sleeping in the corner the entire time, and our entry woke him, prompting him to verbally assault us with displeasure as he fled the room. Dr Nicole introduced herself and began doing an abdominal exam. Ironically, she did it in the exact opposite order I had been always taught to do it. I was always taught to start with palpation using the hands, move on to percussion and then finally listen with the stethoscope. She did it in reverse order, which is how she had been taught herself. When she finally placed her hands over the mass and pressed down, she turned to me and gave me a look and a nod.
Thank goodness, I thought to myself. Idiot I am not!
The patient didn’t want me in the room for her pelvic exam, and so I waited outside. I lingered on the details of our exchange before the examination. The more I thought about it the more I agreed with my differentials. If she had pelvic inflammatory disease why is she pregnant? Definitely she can have both, although it certainly would be nice if I could hear the fetus. Also the intense nausea and vomiting and a mass over the ovary? Almost sounds like a board exam question for a molar pregnancy. When Dr Nicole came out of the room we spoke for a minute.
‘Any findings down below?’ I asked
‘She has a lot of discharge, and her cervix is inflamed for sure.’ She said ‘We will treat her for Pelvic Inflammatory Disease and refer her to hospital, she needs an ultrasound to assess that mass.’ I couldn’t agree more.
‘Okay, I can write the letter if you think. I know she said he has only a little discharge for the past four days, but this is something I have seen so many times here. They can be very coy, especially talking to me, a white man. I sometimes wonder how much they’re really giving me’
It’s not easy to slide in as the boss and be expected to provide answers when you are still figuring out what the rule of engagement are yourself. It was an exchange that marked the beginning of our professional relationship that would bring agreements and disagreements still, but what I liked about her was that it was never personal; we would go on to make a wicked team over the next two weeks. Clinic went late into the evening that night, until 9pm, a regular enough occurrence. By the time we had eaten, packed, and tied up any loose ends, my hammock was calling. I felt supported during my first eight weeks in the field, but definitely still sometimes alone out in the field. That day I felt different, like a weight lifted off my shoulders. I had someone watching my back. Despite the ill-timed calls of roosters, for the first time ever, I slept through the night without waking.
I finally had a partner in crime.
