Last time I went to Ensenada, things got pretty wild. Located across the Chiriqui Lagoon passing through treacherous sailing in the Canal de Tigre, it’s somewhat isolated. Not only that, but it’s the only community we served on that peninsula, and so people come in large numbers from all the neighbouring villages to get their care at our clinics. On that trip I saw over 50 patients in two days, several of them really sick with everything from toxic pregnancies, new nerve damage, to an abdominal infection that triggered an emergency boat journey through a storm of biblical proportions. A certain part of me didn’t know whether to feel nervous or excited about going back. In truth though, I understood that things were so different this time around that the circumstances were essentially incomparable. We also had a little extra backup now, as the team welcomed a contingent of about 15 medical students from the University at Buffalo.

At dinner the night before heading out, we all sat in the dining hall introducing ourselves, and their excitement was palpable; all mirror images of the lad I was on my first journey. Afterwards, as I got to know them and the details of my origins came to light, more and more of them found themselves sitting at my table, crowding one another just to get an ear into the conversation. It’s only in reflection that I realise I became something very powerful to them that I never really felt like I earned the responsibility or the right to be: I was a role model. They saw in me the same things I saw in Dr LaBrot when I first embarked on this career in humanitarian medicine. Whether I meant to or not, that’s something I was going to be just by walking the path I walked. Humbling.

Navigating through the canal proved uneventful despite being lengthy, and the arrival to Ensenada, made considerably easier by many helping hands from the Buffalo crew had us unloaded and set up quickly. Given the long journey, our clinic wasn’t happening until the following day, so after leaving everything in its place, we decided to go to a nearby beach. Not a bad way to spend your Monday afternoon.

Tuesday clinic, with the bolus of new personnel, had us with more help than we knew what to do with. They were so many students, I felt diminishing returns on their impact. There simply weren’t enough jobs to go around, and so we had to pair them off or even form clusters of three for basic things like intake and pharmacy. Despite the clear redundancy, I appreciate that in some sense the goal of their presence was not intrinsically linked to their utility; it was an intersection between the economic model of a group that depends on volunteer fees to provide medical care and an education initiative to provide experiences for future contributors to the field—People often have a lot of criticism towards the principles of ‘voluntourism,’ and I do believe that at times those criticisms are justified, but not always. When I was in high-school a group of students went to the Dominican Republic during spring break and built a school. If all the funds spent on their trip was just donated to contractors in the region, the same money could have resulted in maybe ten schools instead of one, this is true. Some would even go as far to say the concept of going there is laced in white saviour complexes, colonialism, and self-righteous privilege, maybe also true. You know what I did instead though? I spent the same amount of money on a trip to Punta Cana and got blasted on the beach for a week straight. Nobody seemed as bothered by that. Also need to factor in that all it takes is one of one hundred students to be inspired enough on their trip to take up a lifetime of contribution that far outweighs the lost opportunity cost during the trip itself—either way, this all meant was that our capacity for intake and medication dispensing was jacked up on steroids. A soon as patients got registered, the students latched onto their charts like hungry piranhas.

For the few clinical-year students, a bit more advanced, their experience would vary so massively from my own as a student that it wasn’t even funny. The only fourth-year of the bunch (we’ll call him Blair) spent the first clinic day shadowing me, soaking up tips and trick. After a full day of direct oversight, he moved on to seeing patients alone with the help of a translator, and still presented every case to the acting lead before they came up with a plan together. There were relatively few patients, with loads of time to contemplate, eat meals, and fiddle-faddle if inclined. It was controlled, and tidy. In a strange twisted way, I nearly lamented it. It was as if the key features that made my experience here so transcendental, that madness that intoxicated me so much, was now replaced by a regimented and wholesome experience. Don’t get me wrong, these are all good things, and I don’t say this for me as I already had my time for madness. I suppose I lamented it for him because he’d never get to live what I did.

At the very least, we got to see some things that he’d carry with him forever. Ensenada, for everything that had changed since last time I was there, still held the undisputed title of clinic with highest burden of gynecology and women’s health. I remember myself and Blair saw two women, separated by only a few hours, coming in with similar complaints with some nuanced differences.

The first was an overweight woman in her early thirties who had a nonspecific abdominal pain for a few months. During that time she had actually been to a clinic on the mainland, gotten an ultrasound of her gallbladder that was non-revealing, and given a take home prescription for ibuprofen. Probing her story more closely, she told us that her pain was intermittent, coming and going unpredictably during most days of the week with little relation to her food intake. Additionally, it hurt most when she was walking. As we exhausted many of the standard intestinal system questions concerning nausea, bowel motions, and the like, we had little substance to help draw any conclusions. That was until I asked my go-to question of any women with any complaint.

‘How about down below, in your private area. Any discharge?’ I asked.

‘Discharge?’ she answered.

I nodded. She clasped her arms together and looked down at her feet for a moment.

‘Yes,’ she said.

‘For how long? Any colours or foul smell?’

‘A few months… It’s white. Sometimes it smells.’

‘Did it start around the same time as the abdomen pain started?’ I asked. ‘Or maybe before?’

‘Maybe before,’ she said. ‘I had gotten a cream from the clinic but that didn’t help.’

‘How about pain in the vaginal area?’

Her initial nerves at my approaching the subject quickly disappeared, and the story we uncovered helped to shed a little bit more light on her situation. It wasn’t a slam dunk, whitish discharge is common enough, and usually you’d expect it to be quite smelly and thick to be a bacterial infection, but it warranted having a look. With her permission, we stepped away to the private room and I examined her. [1] Her abdomen was tender to touch, and from her vagina she had a notable whitish-grey discharge that wasn’t particularly foul smelling. Visually inspecting her cervix, there was no obvious irritation or blood, but she did have notable pain in her cervix with physical tough. This is something that was historically called the ‘Chandelier sign,’ which refers to cervical infections being so sore that touching the cervix on exam would cause patients to leap off their beds and grab onto a chandelier. I have yet to find in my limited years of experience an examination room in a hospital or anywhere else with a chandelier within table jumping distance.

I am still young though.

Combining her genital exam with a sore abdomen, and all her previous workup, we made a clinical diagnosis of Pelvic Inflammatory Disease (PID), and treated her accordingly. There were a few elements of her story that still didn’t have me convinced though. In theory true PID should be causing fevers, and making patients more generally sick appearing. I would have been more reassured by a fouler appearing discharge as well, but like I have learned time and time again in medicine, sometimes there is no clear answer and you have to make an educated guess with what’s available. Under reasonable grounds, this patient might not have started treatment for PID right away in Philadelphia, at least not until we ran some samples of her discharge to find the bugs we’d be actively treating. There’d be no such capacity for that here however, and it was also her last shot to talk to a doctor for the next three months. If our treatment didn’t fix her symptoms she’d likely have to make a costly trip to the mainland several hours away.

A few patients later we saw a different woman, also in her thirties, whose primary complaint was vaginal discharge. She had a slightly different but also convoluted story. Unfortunately, about three months before we saw her, she had missed a few of her periods. After that, she began having large clots and bloody discharge from her vagina with some associated fevers and went to see a doctor on the mainland that ran some tests and told her she was having a miscarriage. Initially all the bleeding stopped, but a short while after, she began having discharge of another nature, greyish, and foul smelling. She never had more fevers, and the discharge never worsened, but it had persisted. She came to us asking for help. The same series of questions revealed she was having pain with intercourse, a fairly characteristic sign of cervical infection.

Again, we stepped out to the private room to have a look. She was having some abdominal tenderness at the lower third of her abdomen, over the uterus. This time the discharge was foul smelling, I caught a whiff of it as soon as we began positioning her for the examination. When time came to actually physically probe her vagina, insertion of the speculum caused her some notable pain. Oddly enough though, her cervix itself wasn’t all that tender. Again, we found ourselves with a patient that had some features concerning enough: foul smelling discharge, uterine pain on abdominal exam, a history seeming to suggest PID, but no real fevers and a cervix that didn’t seem that tender. This is the part where having a bit of experience helps you make sense of where your patient fits amongst the typical cases in the textbooks. If I had a fancy lab, I could have had a clearer answer, but this is the beauty of medicine without fancy labs. All you have is your brain and your hands. Outside of any speculum, stethoscope, ultrasound, or otherwise, the most powerful tool is the one between your ears. I used the contrast between the two cases as a teaching point for Blair.

‘Not all cases of pelvic inflammatory disease are created equal,’ I said. ‘Especially out here when the risk of missing something is magnified exponentially since these people won’t see another doctor for three months. You’ll notice how neither of those cases were a slam dunk, but they had enough elements, interestingly enough each one of them different elements, that make it a reasonable decision to treat now in the absence of more sophisticated tests. Any questions?’

‘No questions,’ he answered.

‘Alright,’ I said. ‘Let’s grab the next patient.’

I worked through lunch into the afternoon, and by around 2pm things were starting to slow down. Taking lunch at 2pm was a strategic move. In the Ensenada there was a shop with a TV, and I squatted down onto a plastic chair next to some locals to eat while I watched my beloved Argentina play their semi-final against Croatia. Without trying to make it seem like I had screwed right off, at half time I quickly went back and picked up the first available chart to see a patient. Knowing that my conscience could never allow me to give suboptimal care, I prayed that the chart I was picking would be something manageable. It wound up being a woman with asthma who was there to pick up her inhalers. She was pleasant. After I wrapped up with her, I went back to the intake table to find no charts left, and we were done for the day. Once again, clinic wrapped up with time to spare. I was able to catch last bit of the second half, and in the end we wound up having a lot of medical students with not much to do, so another trip to the beach was indicated before sunset and dinner time.

The next day’s clinic had me designated as the triage care provider. Instead of treating patients from intake, I would just form a cue right outside the little shack we had commandeered, and patients came in one at a time. Again we saw a slew of women with vaginal complaints, some that were unexpectedly pregnant, and some that wanted birth control injections to prevent the same. Not that many actually showed up to triage, so I wound up working a half day at that role before jumping ship to help the others work through the chronic patient list. After lunch, at this point with only a few left waiting to be seen, I picked up the chart of a lady in her sixties in a striped woven dress. Her primary complaint was that she needed money to help fund her expensive travels, and fairly quickly it became apparent why, as she was being treated for cervical cancer.

Cancer treatment in the jungle is a bit tricky. Although we conceptualise cancer as a disease of middle and high income countries, the reality is that cancer is possible in the genetic makeup of any organic cell. As a result, whether we appreciate it or not in our global population metrics, cancer can be seen and is seen in all populations throughout the world. Certainly there are specific behaviours which are influenced by culture that predispose people in some places to certain types of cancers over others, like exposure to sunlight and skin cancer in white people like Australia for example, but cancer as a process is common worldwide. The difference in access to care between high and low income countries is probably highest in this domain than in any other realm of healthcare. For example, many central African countries have no national cancer treatment programs at all, condemning their populations to not only fail to recognize cancerous conditions, but render any possibility of treatment completely null. To think that in many places you can’t find an oncologist (cancer specialist) within thousands of square kilometres while in other nations people argue over whether to start screening every single person for colon cancer at age 45 to 50 still baffles me. For those out here in the Chiriqui region, it was a nightmare, take our lady as a case study:

Sometime around 2016, several years after menopause, she began having vaginal bleeding. Through a medical group (unclear whether it was one of our own, or through a Centro de Salud in a neighboring community) she was sent to mainland for some testing. In her case, this would have been either an ultrasound of her uterus or a tissue sample sent to a laboratory in Panama City. With those results, she was unfortunately diagnosed with cervical cancer. Getting access to an oncologist at that point meant getting to mainland, followed by a bus ride across the country in a journey that approaches 15-20 hours from end to end. After seeing the oncologist, she was started on chemotherapy and radiation, delivered in interval sessions every eight weeks over the course of two years, with repetitive trips to the capital and back. She responded well to chemo and entered remission, but once she finished her treatment, part of standard follow up meant regular scans of her abdomen, also done in Panama City every few months. Things were clear for a while until the cancer returned, and she actually had to get surgery to remove her uterus and both her ovaries sometime in 2019. I was seeing her now, a few more years post-surgery.

You can imagine the sheer cost of time, energy, and finances that this placed on her. She communicated some of this to me, although much of the nuances I gathered from a letter that she gave me from her oncology office that outlined the details of her treatment course. I am happy to say that at the time I saw her, the most recent scans indicated she was cancer free. Yet the follow up appointments and scans wouldn’t stop coming, and she was desperate to try and get some financial support from us. Financial support that we didn’t have. The budget we had was the budget we had for a reason, and despite wishing I could cover the bills myself, there wasn’t much that I actually had to offer her.

‘I’m sorry,’ I said. ‘You know if I had this to give you I would. We don’t even have all the medicines here I would like to have.’

There wasn’t much else I could say.

All in all, it was equal parts saddening but gratifying to see that despite all of the obstacles between her and her care, somehow we were sitting here 6 years after her diagnosis holding a conversation when she should have probably been long dead. If anything, it just brought to light the chasm existing still between western standard of care and these populations, and that’s with the presence of a group like Floating Doctors coming to your community. Most people all around the world don’t have so much as a fighting chance. It’s easy to let those realizations dishearten you, and at times they do, when you understand that there’s so much work to be done. However, all it takes to feel hopeful is to look around.

That night, in one of our hammock cities, I sat down with Ber, Lisa and another doctor as we did case rounds with twelve medical students. Twelve future physicians with nothing but an entire career’s worth of time, energy, and passion to make a positive impact in these places where it’s needed most. The excitement with which we dissected cases, seeing eyes widen as teaching concepts clicked into place, and an endless stream of questions about the humanitarian experience filled me with immense pride to be embarking on this journey, because on this journey we are not alone. Maybe it’s just a coping mechanism, a strategy to deter the cynicism of a corrupt world from eating up my expectations and desires for positive change, but I have to believe that so long as I trust in my mission that others do too, and no matter where they are, be it in some distant corner of the world in a conflict zone, in a busy community hospital, or in a shack somewhere with nothing but hands and a desire to do good, that we are in this struggle together. That’s what’s so beautiful about this career.

Not everybody feels that way about this job though. Some people, for better or worse, see it as just that, as a job. A job like any other, that you like on some days and don’t on others. The amount of physicians I have worked with, both young and old, that sleepwalk through their days counting the seconds between them and going home is too high to count. They are everywhere. I don’t know where the blame for their attitudes should go. I am sure many of them started in this field with just as much passion as I did, some of them maybe gradually worn down by unforgiving cogwheels in the monster machine of 21^st century medicine, I can’t say. All I can say is that to me it’s so much more than a job, it’s a way of life. It’s a purpose for being that feels greater than myself and my own need for happiness or joy. The day I lose sight of that is the day I’ll hang up my stethoscope. For better or worse, we’re in this for the long run.

You with me?