The second day of deployment was going to be an improvised affair. Jack had agreed to check in the wifi rock near the school periodically with our driver to determine if the road to Bajo Cedro remained closed due to the protests. At 7am it remained closed, so we agreed to set up clinic at least until 10, when we would check again. A handful of patients turned up after word got around we’d be staying a little longer than first anticipated. Most of the morning was fairly laid back. For the first time ever the intake list was longer than the provider list, and I was able to keep up with the admin table as patients came in sputters throughout the day. At ten, word got back to us that the road to Bajo Cedro remained closed, so the decision was made to stay until our final departure time at 1pm. As murphy’s law would decree, an influx of patients at 12 meant that the last hour was hectic, and all hands on deck ran in circles to try and ensure that everyone got seen.

It’s not unusual for my consults to provide more need for innovative thinking than actual biologic medicine. Both due to my clinical inexperience and our limited resources, even when I didn’t know what to do there was not much that I could do. It’s not like I had the resources of a hospital at my disposal without the clinical acumen to know how to use them. For example, take the following woman I saw towards the end of clinic with arthritis:

She was in her late thirties, and had bilateral joint paints in her hands and shoulders. She sat in the clinic across from me in a posture like a baby dinosaur, with her arms tight to her body and her elbows flexed. Going through her previous charts that we had in our paperwork she had already been extensively examined by previous medics, literally all of which would have had better clinical skills and knowledge than I. Her pain was in the hands, although it didn’t follow the typical Rheumatoid arthritis pattern of prolonged stiffness with pain in the morning that got better as the day wore on. Her hands had none of the rheumatoid features, and the large joints of the shoulders seemed to be the most implicated. Nothing I could find was hot, or swollen, but they were all fairly tender. She also had an increased tone (rigidity) in her arms. Trying to pull her elbows off her sides was a difficult affair that made her very sore. Even her ability to squeeze my hands was implicated with reduced power.

In America, Ireland, or even mainland Panama for that matter, there is a battery of blood tests that would provide answers. Even if the results were negative, we could determine what it wasn’t, which was clearly an unusual manifestation of joint disease due to god knows what. If I was the intern seeing this patient in Ireland I’d have a lot to digest, deciding on what set of tests to deliver, knowing that you always have to be careful and not send the wrong ones, because any positive resultswill lead you down a garden path that you don’t want to pursue unless it’s indicated. Antibody panels, rheumatoid factors, inflammatory markers and the like. All I had here was my set of hands and a portable hemoglobin device. Even if I wanted to I’d never figure out what was wrong with her. Her story had a couple extra wrinkles however.

She had been to see a specialist, finally after a long back and forth with us and the local hospital. They had seen her and prescribed a drug regimen that was working in conjunction with some creams they taught her to make at home. Things were going well and the treatment was working, that is until her house burnt down seven months ago. Everything was lost in the fire, including her prescriptions and prescription notes. Enter Dr Bozo:

She wanted me to help treat her arthritis, and I explained to her that what she was experiencing was a very unique form and I had no way of knowing what she was given. She didn’t recall the colour of the shape of her pills, only that she took one twice a day. Knowing that all I had was Ibuprofen and Paracetamol we developed the following strategy as a team. I gave her two bags with sixty tablets each. We labeled one bag A (parAcetamol) and one B (iBuprofen) in permanent marker. I gave her written instructions to trial A first, twice a day, for a week. If that didn’t do it we would try B. If neither worked we could try a combination, and I instructed her to keep everything including the written note for her next visit to see what worked. In the meantime I would discuss with the boss and see what more we could do.

Thus I sent her off into the big bag world with some careful conversation and two baggies of over the counter medication to control her crippling arthritis. I would realise later that foolishly I didn’t even ask what hospital she had been seen in, which would have enabled me to try and track down her records from the base and send her something of real potency between visits. I also didn’t check her hemoglobin, which should have been one of the first things I did since rheumatoid arthritis can cause anemia of chronic disease. Like always, for every stroke of good thinking, there were things I constantly forgot to do. How on earth do people remember to do things right all the time? As much as I was loving life being the man, I had to recognize that I was just doing the best I could, not the actual best. I wonder how far I will get in my career before that feeling goes away. I imagine probably never.

I also saw an older lady who said very little, and had me running around in circles to find out if anything was wrong with her in the first place. She was coming to pick up her medications and just sat in front of me, looking annoyed. When I asked her what I could do for her, she looked completely uninterested. It was as if she was the prettiest girl at the bar and I was just a generic frat boy who she’d written off as being a dickhead before he even approached her. I can never tell if this is a cultural thing or not, why are some people so friendly and others make me feel like I am wasting their time and being a jackass for trying to talk to them. I wonder how far I will get in my career before that feeling goes away too. I imagine probably never.

Wrapping everything up was a bit hectic, as a patients turned up seemingly one after another for a quick pregnancy test, or a shot of depo. One guy came around with eczema. I gave him some coconut oil and told him to check back in with us at the next clinic if things didn’t get better. A quick stop to eat lunch and we were on our way back home. Bajo Cedro would have to be worked into the rota some other time when we had access.

As we arrived back on base I noticed a few things had changed. There were notes on the fridge and on the sink that resembled those from when I was there in isolation. It had a woman’s name written on it.

                ‘What’s all this about?’ I asked. I can’t remember who.

                ‘Oh that?’ Someone told me ‘That’s Nicole. She’s the new doctor coming in tomorrow. Some things fell into place so she’ll be taking on the role of lead provider for the next five months. Isn’t that exciting?’

Finally some respite for the people of the islands. A real doctor was coming to town.