There was already a crowd of people assembling at the concrete path that lined the main artery of the village. I came up to find the horse, standing idly, as if nothing concerning had happened at all, and a group of paisanos standing in a row. At first I thought to myself, Okay, this seems rather chill, the boy is probably fine.
‘Where is the boy?’ I said to Jack.
‘There!’ He pointed off the path to the right. I squinted in, and saw what looked like an odd lump. As I walked closer I realised I was on him. A boy, probably not older than thirteen, out cold laying splayed out nearly hidden by the thickened carpet of tall grass. I immediately dropped the bag, and knelt down next to his head. I asked the people standing by for his name, and heard only silence. ‘Hola?’ I shouted at him. ‘Can you hear me?’ He laid there motionless at first and then his torso arched forward, nearly forgetting his head behind him, in a sort of automatic dry heave. ‘If you have to vomit, go ahead and vomit’ I said to him. He jerked once and then resumed his lifeless position. A reefed my fingertips into his shoulder and squezed as hard as I humanly could, nearly hurting myself. Nothing. Not a flicker in response to pain. Right away that told me that his GCS (Glasgow coma scale, our crude measure of level of consciousness), was in the danger zone. What happened next was automatic, the countless hours of training I got from the RCSI SIMWARS emergency medicine simulation tournament saved my skin. I was almost on autopilot, surprisingly calm; I had done dozens and dozens of simulations just like this, and they always start the same way. I knew that my job was simple: Airway Breathing Circulation, our bread and butter in the emergency department. I pressed my fingers to his neck, he had a pulse. Using my watch I got a basic heart rate. 125 bpm, I called to Jack and told him to write it with the time. I dropped my head to the level of his mouth, he wasn’t breathing, at least not at first. After five seconds he heaved for air. His breathing was clearly irregular. Jack was sat next to me with the airway bag open. I asked him for the pulse oximeter, and we put it on his finger. Low and behold it wouldn’t turn on.
I grabbed our boy by the sides of the head and bent his jaw up to the heavens. He was breathing now certainly, it was just erratic. He wasn’t blue, and I took that as good enough. Hopefully just winded after the collision, I thought. A freaking horse fell on him. I am not sure why but I was immediately worried about a pneumothorax, for some reason that is the first thing that came to me. Using my stethoscope I listed for breath sounds in either lung. Both lungs were clear. Okay I thought. We’re decently stable. A and B. I felt against his pants and turned over his back, his shirt already pulled up, no major blood loss anywhere. That’s C.
I shouted to those around me for some information. What happened? Who is he? Does he have any conditions? Nobody seemed to have an answer. I would only realise this later, but this boy was one of two who had descended down the mountain from la Sabana with our pack horses. Nobody knew anything about him except for the other horse bringer, who was MIA. Finally someone gave me a name, and a story. He had been riding one of the horses on the path, which was elevated off the soil by about half a metre over the creek nearby. The horse mis-stepped, and both horse and boy took a tumble, only for the kid to be pinned against a tree next to the path as the horse fell into him. Lo when he finally hit the ground, the horse fell on him and gave him a good stepping. A firm squeeze of the traps and more calling his name game me no response. Okay, so I’m worried about D, disability. I pulled out my phone, lit the torch and assessed him for pupillary response. It was so bright outside, it made it difficult to appraise it any decent way. I honestly saw almost no movement, but they were tiny to begin with under the cooking beams of sun. Someone shouted that he had a history of faints. Okay, I thought, maybe a fall, winded? How long do I wait for him to come to? I sat there in silence for a moment, just watching. Monitoring again his heart rate, his breathing, again his pupils, still no response at all from trap squeeze, heart rate, breathing, pupils, another squeeze. I looked down onto his belly and ants were crawling all over him. Jack said to me ‘What do we do?’ I knew there is a medical post nearby, very simple, just building stocked with a few medications. I deliberated internally for a moment. Jack, as well as the villagers, were hanging on my word. What happened next was my decision and mine alone. We had an entire other village that was waiting for us up the mountain, hadn’t seen a doctor in any form since the summer. Yet in that moment the duty was to the boy infront of me. I knew what he needed. An acute loss of consciousness after a fall was grounds for a CT, not to mention he needs Xrays, and close monitoring. They didn’t have any of that in the medical post. The nearest hospital was God knows where, but it didn’t really matter. We could call and ambulance I thought. Oh wait that’s right. We are the ambulance. Decision made.
‘No no, we’re going to hospital. If that means we’re not going to la Sabana then so be it. I need someone to grab me a sheet or a big towel or something. We’re moving now’
Jack ran off. I knelt there still. ABCs. ABCs while I waited. With some help from the villagers we managed to sit him up and drag him onto the concrete path away from the ants, C-spine precautions be damned (not my finest). His feet below him were finding ground but he was on glass legs, and his neck muscles were completely hypotonic, causing his head to flop about onto his back and shoulders, like a broken bobblehead or newborn baby with a big skull. His eyes were still shut, and a vicious trap squeeze still gave me nothing. Somewhere somehow an old rickety stretcher arrived. We loaded him onto it, I took the rear and two paisanos took the front.
Jack stayed back and was making phone calls to arrange transport for us to the hospital. It would take us about ten minutes to walk back out over the bridges on uneven terrain hauling dead weight. I remember no one walked with us. Just the three of us in complete silence, under the piercing heat carrying this boy on the stretcher that felt like he weighed a ton, what is it about dead weight that does that? I suggest we bring back Isaac Newton from the dead to look into it. I kept my eyes glued to him for any change in status, not to find any. For those ten minutes my mind went oddly blank. I just remember the heat, and how my hands felt locked onto the stretcher, like the jaw of a pitbull. At one point in the middle, crossing the second bridge, a bizarre thought just popped into my brain that seemed inappropriate.
‘This is it’ My mind said. ‘This is what I want to do for the rest of my life’
We walked up off the last bridge, up the hill and landed at the first bus stop opposite the highway. We laid the stretcher on the ground and I again resumed my ABCs. I couldn’t feel a pulse, or maybe I could. My fingers were throbbing from gripping the stretcher, and stiff, fixed into a claw. I tried again, and thought I felt my own pulse reverberating, not his. I felt something, and he was still breathing, presumably if he’s breathing he has a pulse I thought. Every time I glanced to look at my watch I felt like I lost the pulse. It was definitely there but I couldn’t get a rate. I could feel that it was quick. Jack arrived behind me and said there was a car coming and we loaded him into the back. ‘I’m going with him’ I said. I had been told so many times of how the Ngäbe were so often neglected at the point of care. I figured a white man going with him would bring some more merit to his arrival. I tried to call the boss, but there was no service. As I continued to monitor the ABCs in the back of the car I sent him the following texts:
- Kid fell off a horse we are taking him to Rambala Hospital
- ABCs are stable he’s breathing and pulse is 125 but not responsive to pain decreased loc
- Out cold since probably 2:40 (text timestamped at 3:10)
Right as we were pulling up into the hospital after a fifteen minute drive, he began to open his eyes, although he still was not making a sound and had no idea which way was up. Arriving at the hospital things were set up outside under a tarp in full covid fervor. I gave the story to the triage nurse. I lied and told her I was a doctor, and what happened. I said he was unresponsive at first ‘Glasgow?’ She asked. I drew a blank. She was asking for the Glasgow score raw. I couldn’t remember what was what in there. I know one was 6 points, one was 5, and one was 4. He was getting better as of the last two minutes, I wanted to give her a number that was concerning but indicated things might still be okay. ‘Nueve’ I said. That was another lie. I did the math later and he was probably at a seven. Lesson learned kids, know your GCS.
Over the next half an hour I sat at his bedside at the Rambala hospital (which is more like a clinic than a hospital, with no Xray machine or CT, although fairly clean and decently equipped as a kind of triage centre for patient transfer). They hung up some fluids for him as he slowly regained some level of function. He was able to talk, recalled his full name, and knew that he was riding a horse. He also told me it was 2021, we were in Panama, and that his back was sore. I hung around for a time. Jack, who was with us, was busy on the phone trying to contact a next of kin. It was too late now for any family to begin the journey down the mountain, since the pass couldn’t be made at night with risk of rain, and besides we had no way of reaching anyone up there. He worked his magic. It took probably two hours but somehow there was an uncle somewhere in the area, and he met us at the hospital before our boy was transferred to Changuinola Hospital, a solid modern place of care, two hours away for CT and Xrays.
I was able to eat, and by the time the sun had gone down around seven we met back up with Chrys at the village. He had sent our gear up the mountain to La Sabana, so we would trek up there the next morning, do clinic and spend the evening, and descend the following day where we would do a Depo-provera birth control injection clinic in Pueblo Nuevo. With our plan laid out I took a moment to catch my breath, before heading down in the darkness to bathe in the river with Jack as my guide. We came back up to the rancho, and were setting up our hammocks when a woman came by, she needed us to come see her daughter who was unwell. I grabbed my stethoscope, facemask, shield, and notebook. Then I put on my headlamp, and I asked Jack to bring the medical bag, and we followed her to her daughters home. No rest for the wicked.
She lived in a modest, elevated wood plank house. Probably the size of a standard living room. There was roofing outside with a bench underneath. I was greeted by the daughter, a girl of 17 nursing a seven month old baby, her mother, and aunt, a brother maybe, and six little children who crawled all over me, tugging constantly at my shirt and stethoscope as I gave her a consult. The seven month old had recurrent fevers since birth and would often vomit. The symptoms were non-specific, the child looked well and was tracking decently on her growth chart which the grandmother had in hand. I wasn’t terribly concerned. I said I would be worried if she stopped urinating or pooping, or her weight was less than it should have been. Recurrent reflux in children and the odd fever was no big deal. I said to leave it with me and I would talk to the boss and get back to them if I had any other concerns. Then I turned to her mother.
She described vague symptoms of gastritis i.e when she eats the gets nausea, for the last two months. No abdominal pain, fever, vomiting, or bowel changes of any kind, no cough or phlegm, energy perhaps a bit low, appetite was meh. I cleared all the children off the bench, asked for a blanket and began an abdominal exam with my headlamp turned to dim as not to jar her. I palpated the nine quadrants, like I had been taught to many times in clinical OSCEs and done on the wards. I got to the lower third and I felt a mass: Soft, in the suprapubic region, but firm. Feces? No she’s had no constipation. What else might this be…
‘When was your last umm..’ I hesitated. Her whole family was right there in my face. ‘Your last feminine cycle?’ At first she didn’t understand. Your period damnit. After a moment she it made sense.
‘September was the last. I haven’t got it since’ she said. I was cognizant that she had just given birth seven months ago.
‘Breastfeeding? How is that going’ I asked
‘Going well’ she said. She had given birth in April. Her period came back a few cycles and was last in September. Bingo Bongo, your one was pregnant. Of course I had no way to confirm, but I would have bet the house on it. She was 17.
I asked her if we could talk to the side. I asked her about sexual activity, which she was active. I told her that I thought she was pregnant, but I had no tests. I would be back the day after tomorrow to give depo injections, and I could get the team to send some pregnancy tests with the materials. I promised that I would come find her when we came back, even if she didn’t show at the clinic. ‘I won’t forget’ I said. You should always be careful when you say that. I left her with that and we walked back to the Rancho.
Sitting in my hammock, I think it was only then that I took note of what transpired that day. These were not only my first patients in Panama, these were my first patients ever. I thought about how far I had come in just one day, and how I managed. I tried to read out of my book, Orwell’s 1984, but I was honestly too tired. I shut off my headlamp, and laid to rest suspended in my hammock. The sound of rain and traditional Panamanian music (typica, as the call it) sounded softly in the distance, accompanied by a symphony of roosters who cackled from the silence abruptly as if they were watching sport. The roosters would keep me up all night. Jerks.
