The next morning we rose groggily and got ourselves in working order. Rain was coming down now in high volumes, and low cloud coverage coloured everything of cloth with a layer of damp. Clinic started okay. I saw a few patients with really out of control asthma, one was a lady in her thirties who sounded like she had a dozen kazoos inside her chest. It’s difficult sometimes to tell whether patients are in a bad spot in that moment or if this is what life is like for them all the time. This lady was still taking her inhalers, and I wanted to try and parse whether she was having an exacerbation of her disease or if this was her chronic state. A good way to do that is to look at the place that contains the most information in the human body – the hands.
The hands, believe it or not, are a gold mine for investigation of chronic disease. Blue fingers are a telltale sign of chronic low blood oxygen, tar stains on the fingers show you a lifetime of smoking, calluses provide insight on years of manual labour that implicate all parts of the body, and bony swellings tell the story of different forms of arthritis. Some patients with anemia (low red blood cells), can develop spooning of the fingernails, called koilonychia. The fingernails can also show signs of tiny clots launched out of the heart during infective diseases, or discolorations that can indicate deficiencies in minerals like calcium and zinc. Likewise, poor respiratory function or chronic inflammation can cause changes to the tiny arteries that terminate in the finger tips, which can lead to clubbing of the fingers, or widening of their tops that resemble the tips of drumsticks. The hands are always where I was taught to start during any examination of the body, or of a system, and it is still where I start today.
This lady had nothing to indicate that she had chronic low blood oxygen in her hands or face, which led me to think that she was in the midst of an exacerbation of her disease. This would require an oral course of steroids, which I didn’t have on me. I told her to leave it with me and I would send some back for her when I got the chance. I always wonder how that makes patients feel when they are told to trust that I’ll deal with it another time. Do they really expect me to follow through, or do they think it’s a possibility I won’t? The health system has failed them so many times, I just wonder if they expect that our care might be no different. Either way, they always put their trust in me, and never once have I been given grief for not having something right there and then. I often think about how many patients I met in Ireland that insisted on getting antibiotics for the common cold and refused to leave without something in hand.
We didn’t have a huge amount of registrants. I was actually able to take my time for one or two, and go above the call of duty to explore some finer things of diet, and lifestyle. One woman just wanted a blood pressure reading, and I got to spend close to half an hour with her. This is how medicine should be, I thought to myself. After seeing her Jack pulled me aside, which was odd.
‘There is a girl on the list that I think will have to come back with us to hospital’ he said. This took me by surprise, Jack never made those kinds of decisions. ‘What do you think? It’s this girl over here.’ He pointed to a young girl sitting in the corner with her mother. She was bent over in pain, and had tears in her eyes. They were sitting patiently for their turn in line.
‘Of course’ I said. ‘I’l take a look at her and we’ll see. We have room in the boat so if she needs it, then for sure’.
When I came to her an hour later, I sat them down in front of me. The girl was sixteen, she was walking slowly, on eggshells, and sitting down she winced and laid her head against her mother’s shoulder. The first thing I did was tell them to hold on, and grabbed a paracetamol tablet with a glass of water and gave it to her. As we sat down Mom began telling me about the last four days, and what her daughter had been through. Four days of abdominal pain, stabbing, in her suprapubic area, she was also having discharge down below, which was white and thick with an assaulting smell. There was also blood, and lot of it, almost a cup per day, coming out her vagina. She had a fever that mom was managing to dull with paracetamol, her last one taken at four in the morning that very day. When I saw her she had a mild fever, and her vital signs were stable, but she looked awful. Trying to talk with her was like speaking to someone 11 cocktails deep, she was drowsy, lethargic, and her eyes looked empty. Alarm bells were already ringing in my head. Her mom told me she wanted to go to hospital yesterday, but they didn’t have the money or the means. Things weren’t pretty, but I had to at least be thorough. I asked about all the symptoms, no diarrhea, although she had intense pain with urination. Her last menstrual period had been two weeks prior, and then all this started ten days later. She denied any sexual contact vehemently.
I took them to the examination room and began taking a complete gynecological history. She had been pregnant seven months ago, full term, and attempted to deliver at home. Labour was difficult, they tried and tried for two days and nothing would come out. In a panic, Mom boated her to the nearest hospital two hours away. She had an emergency c-section followed by another pelvic surgery in the same sitting. Mom didn’t know the details of the second surgery.
‘And what about the baby?’ I asked. Hardly looking up from the sheet I was scribbling notes on.
‘The baby died’ she answered.
Dear God, I thought to myself. I reached out my hand and set it on her knee.
‘I’m sorry’ I said. She was fifteen.
Since the surgery her periods have been irregular, which they never were before. Sometimes they came early and sometimes they came late. I got her up onto the table and her examination sent me into a frenzy.
She had exquisite tenderness in her abdomen, all across the lower third. Just resting my hand on it was enough to make her wince and reach out to grab me. I tried again, resting her hands at her side. I told her that I was sorry and that it was going to hurt, but I had to see if there were any masses, or something I might feel which could give us a better idea of what was wrong. Even with all that coaching, and mom helping at her side, as soon as I pressed lightly on her belly she was clawing out against me. Tears still in her eyes, I decided that was enough. Now to try and see what’s going on below.
I got mom to stand next to me, and I tried to spread her legs, which were tightened like a vice. I almost had to dig my elbows in just to get enough space to have a look at anything. There was a foul smelling, milky white discharge coming out of her vagina. In her perineum, the space between the vagina and the anus, she had a black nodule the size of a blueberry. I gently pressed my finger against it, and she nearly jumped off the table in pain. I asked her to be brave, and putting coconut oil as a lubricant onto my gloved finger I tried to spread the labia and she winced again, nearly crying out. I couldn’t go any further. There was no point. We were going to suspend the clinic and leave right away. There were four patients still on the list and we’d have to say sorry. I told the mother to get their things ready because they were coming with us. She had to collect some things first she said, and we could get them from their house just across the bay on our way out. I nodded and stepped outside. My heart was racing. Jack was taking lunch and so I got Iraida to stop what she was doing and told her to come with me, I wanted to call a snap meeting right away.
We found Jack in the kitchen house and I called him to come outside. The rain had just let up, although the sky still looked miserable. My feet within my flipflops were spritzed with mud from my careless stomping. We stood outside in the muck as I began to say my part.
’Jack we have a very sick lady. You know the one.’ I said. ‘I wanted to call this meeting with all of you because I want us to decide things as a team. I think she is very sick, I am very worried. I want to suspend clinic and leave right now. What do you guys think?’
‘Right now?’ Jack answered ‘How many patients are left?’
‘We have four left, we’ll have to apologize’ I said ‘I know it’s not ideal’
‘I don’t like that’ he said ‘These people have waited, can we not see them and leave after? Also I don’t know if we can sail today. The weather is very bad. The locals are telling us not to go.’
That was not good news. The weather had been awful for the last day and a half straight, with wicked rains and violent wind. The locals know their stuff. If the water was too rough we couldn’t go, especially not through the Canal de Tigre. I stood there, my heart still racing, and we all thought it over. We bounced ideas, and discussed it as a team. I thought about the girl. How might she fare? I asked myself. I had gone through my decision while I walked to the kitchen house a dozen times. If we were in Ireland and I saw her in the emergency room, I would have stopped my exam early and called the surgeons right away, period. It was the most significant and alarming exam I had ever seen in my career, and a fever, and her history, pelvic surgery at fifteen and a stillbirth? She needs a hospital. What was I going to do? I’m not even a fucking doctor yet.
‘Okay.’ I said ‘How about this. I will go talk to the Captain. He knows water, I don’t. If he says we can’t sail, we don’t sail. In the meantime while we pack things up I will see the last few patients. The girl and her mother have to collect some things first. I think you are right Jack, we can see the last before we go. That is a plan that I propose, but I want us to discuss. Iraida, what do you think?’ I let the question linger. I realize now, with the benefit of hindsight, that the way I phrased this question, and the way I approached the entire discussion was biased. I wanted to articulate my concern and my opinion, but it wasn’t fair, even though I was more than happy for someone to disagree. A part of me maybe wanted her to say we shouldn’t go, because that I could rest on that we had thought it through and weren’t all on board. I was already stressed as all hell. An important lesson learned.
‘I trust the captain. If he says we can sail then we sail’ she said. What a warrior.
We broke away and I felt my heart throbbing in my ears. I walked down to the dock. Marlon was chitchatting with the locals, having a laugh. I felt like a bit of a dickhead going in there and pulling him out.
‘Marlon, a word please.’ I said. He walked with me over to one side. ’I want to let you know that we have very sick girl. I am concerned about her and I want her to come with us to hospital today. What are the conditions like? I don’t know the sea, and you do. I trust in your judgement’
‘Look. It’s very rough.’ He said. ‘We can try and see what state the canal is in, and turn around if we have to.’
‘Marlon’ I said ‘I really want you to be the one who decides. I am sorry for how I have done this, I don’t mean to put pressure on you. The reality is that you are my expert on water. If it is too rough to sail then we do not sail. I know patients, and you know currents. Myself, Jack, nobody else knows these waters like you to. Tell me this… If it was up to you, would you go?’ We had maybe been an hour now without any precipitation, but still the sky was raw, and streaked in darkened silver.
‘If it was up to me,’ He answered ‘we go.’
