Tuesday morning, 6:26. A loud crash woke me up, jolting me in bed like a startled rat. A swimming pool of water must have been dropped on the casito roof above me, all at once. It’s not unusual for the rains to start like that, in a flash, like a hammer descending from the heavens delivering a slap of moisture to the face of non-believers. I groaned in bed. We were set to sail out in 35 minutes time. I hoped to god it would let up quickly and crisis be averted. I got up and moved. Collecting the last of my things I bundled up in my Irish rain gear, the trusty green rain jacket that never failed and my full length rain pants. I decided against shoes, and donned the flip flops. The team was bustling like mad already to get the boat packed in a hurry, and helped them with as much as I could loading the boxes and boxes of rice forming the girth of our cargo. The rain continued to pour, and I felt a trickle into my coat up my sleeves while I was loading boxes. For better or worse I figured I’d get wet to some degree one way or another. That turned out to be an understatement.
We motored out from the island into a cascade that formed a mist resembling TV static. The sky above was pure shades of grey, like a blank page sopping wet with water colour. Despite my position hunched over to keep the length of my back against the hardest drops of rain I was leaking water. In no time at all I was completely drenched, down to the crudest annals of my anatomy. I thought I knew rain, Ireland has lots of it. The kind of rain that Ireland has is a gentle patter. Irish rain is that friendly woman next door who does pilates all day long with Shania twain at full volume to keep her going, the noise more notable for its continuity than intensity. This however, was jungle rain. It was the lad across the road drilling the pavement with a jackhammer, while his buddy cut tiles on the driveway with a wet saw. His very presence no matter for how long made your brain rattle. Usually he’d go no longer than an hour, but on this day he had deadlines to meet, and he hammered all day from dusk til dawn and then some more. The entire boat ride we got soaked. At one point I turned back and saw that Marlon, our captain, had opened up his rain jacket, figuring he was probably better off just not to bother.
We stopped at a little post along the way, a kiosk on one of the islands, and while we were changing the propeller on the boat I overheard Marlon’s conversation with a gentleman on the dock.
‘Oye, is that propeller a 17 or a 19?’ he said. He had the look of a man that lived boats and smelled of seawater.
‘19’ Marlon answered, looking up from his work. ‘Can I borrow a little clip or something to change the line?’
‘Sure thing. Where you headed anyways? In all this rain!’ The old timer asked
‘Bisira today. We are a medical team heading up to the community’ he answered, still focused on his work. The old timer laughed. Then his faced went dull.
‘You’re not actually going up that river are you?’ He said.
The Cricamola River opened from inside a massive bay, so wide in fact that I was convinced we came from Open Ocean until Marlon told me weren’t. We rounded a sort of ecologic breakwater that followed up into a point at the river’s base. The locals waited in a wooden hut just at the mouth, resembling a sort of outpost, and we switched our gear into their boat. That outpost I would later learn was actually a restaurant funnily enough. With the rain still lashing at us like thousands of cold tiny daggers, we maneuvered the river with one of the locals taking lookout at the front of the boat guiding our new captain. The river waved and withered like a snake. Periodically we passed small little communities, collections of maybe a dozen houses on marsh-like shores that were completely flooded over with mud-brown water from the river. I didn’t see anyone on the ground, all of them in their houses raised up on wooden beams, but I figured they must have to canoe from house to house during flash floods. For close to an hour we motored deeper and deeper into grey skies and emerald bush, until we reached Bisira.
Another lengthy walk, caked with shallow mud at first until clearing into rock paving and then concrete path brought our equipment to the rancho. A man was waiting there, he was tall, and built strong, like a retired boxer, who loved to chat. We took turns keeping watch of our supplies as we went back in shifts to bring things over, and he and I struck a conversation. He lived opposite the Rancho, he told me of the intense poverty in his community. He was glad that we were there to help. There was a health outpost in the community but they were always out of everything he said, with basic things themselves often out of reach. ‘It is native tradition and culture to defecate in the river’ he told me, ‘They built this bathroom here but nobody uses it. Never poo on land, always in the river.’ Kind of makes sense if you ask me. Once we had everything set up it was close to 1pm and geared to fire up the clinic. I was still wet from head to toe, so I asked my new friend if I could use his bathroom just to change. In the 30 metres walk back to the rancho from his toilet I was already soaked again, so much for trying.
We attended patients all through the day. This was a newer community on the Floating Doctors roster, and so I encountered many patients with chronic disease who we’d never seen before and we had no files on many of them. I attended them as best I could and made notes to add them to our chronic patient list. Most of them were meant to get their regular meds from the health post in the village but they had run out. I saw a woman with wicked epilepsy, on a double dose of carbemazapine and gabapentin, who had been out of drugs for four months. She was having seizures three to four times a month, she came to see me with her daughter, she was also diabetic and dependent on insulin. The pharmacy stopped carrying insulin when covid hit and supply went thin, so she had been taken metformin for a time until those ran out too. We gave her a bit of what we had knowing it wasn’t going to do much. We ran out of our excess supply of amlodipine and metformin within the first four hours of the clinic that day. After that every patient with uncontrolled hypertension and glucose readings in the 300s got just a physical and counseling, we had no drugs left to give. I told them all I would look into sending some up next week not knowing if it was even possible, I’m still trying to sort that out as I write this. The clinic was still going strong, and it the sun was beginning to set, with still a dozen patients more that had been registered and waited patiently since 1. I looked up to the ceiling of the rancho and made a small discovery.
‘Jack’ I said. ‘Are we going to have light?’ One of the patients answered for me
‘No Doctor, there is no light here’
‘Kelly, had we got like… I don’t know a lantern or something? We can’t just treat people in the dark surely.’ I said to her but also to everyone.
‘We don’t’ she said.
I tried to pick up the pace but it was a moot point. By eight o’clock in the evening I was wearing my headlamp, doing cranial nerve exams and covering the beam so as not to blind the woman across from me. I could barely see behind the face shield on top of that. Isn’t it funny to think that something as basic as light was difficult for us to get. I was trying to assess a girl, 16 years old, who first came to us for a refill of inhalers. She wasn’t on our list, and I had done my best to determine the extent of her disease. Her lung sounded clear, but her peak flow capacity was well within the asthmatic range. Just to round things off I asked like I usually do if there was anything else, any other ailments she wanted to tell me about. ‘Just headaches’ she said. Of course. Everybody gets headaches, I nearly have one right now. I was essentially moving on as I asked the automatic follow up question, just waiting for her to answer so I could let her go and wish her well.
‘In the morning or at night? Any nausea or vomiting?’ I asked.
She told me ‘yes’
’Yes to what’ I asked. ‘Both. In the morning, and nausea’. Hmm alright I thought.
‘How often are these headaches?’
‘Every day’
‘Actually every day though or just often enough’
‘Every day’ she said. ‘For the last four months’ She was staring at me blankly.
‘Tell me a little bit more’ I said. She went on to tell me about how her vision had been slightly blurry. She would forget things. I asked her to follow my finger, just as a primer. I moved it from left to right and she followed, then I brought it back across the midline and her eyes darted back. She stopped and closed her eyes. Let’s try that again I thought. Same result. She had some degree of nystagmus in the horizontal plane, she found it uncomfortable, she even asked me to stop. Going through the rest of the cranial nerves she had one-sided numbness of the face, difficulty puffing out her cheeks. I moved down her body to the arms, also one-sided numbness. I was concerned. She had seemed throughout the consult just a little slow to me, but I realised now it was quite significant. I asked her to give me a minute while I spoke to mom.
Mom and I whispered five metres away, leaving her poor daughter in the dark, although not far.
‘How is she doing?’ I asked mom. Mom told me she was worried about her asthma, although that was the last of my concerns. I asked her about school, ‘does she have friends, has she always been this…’ I searched for the word, but I couldn’t find one in Spanish, a diplomatic way to say what I was thinking ‘stupid’.
Mom didn’t flinch, she knew exactly what I meant. No she told me. ‘Oh and about school, she just failed the year.’
I thought about what to do. I wanted her to be seen by a neurologist. Good luck. Also with her presentation, her demeanour, fat chance anyone giving her the light of day in the emergency room, even with a letter. I told her to leave it with me. I would have to talk to the team, try to find how we can get someone to see her, someone in Changuinola maybe, a brain person. I had no way to give her an answer now, with no internet or phone service this far up the river. She was very thankful, and put her trust in me that something would become of this. Another thing I am working on as publish this post. I can’t imagine she is very hopeful, if nothing happens at all that might not even register with her, at most when we come back in three months she might say it to whoever is in that clinic. She probably wouldn’t even. Laughable in comparison to so many of us back home. My mind went back to a patient from Beaumont hospital I once saw chewing out the senior registrar on rounds when I was with nephrology ‘you said you would do this and it never happened!’ he said. I remember he had a point.
It was now 9 o’clock at night. I had wrapped up all the patients. While I was busy the team had decided we’d set up shop inside an old school building across from the rancho. It was held up by decaying wooden pillars, with a stained concrete floor and a rancid smell. Filling its empty space were two corroding bunk bed frames. Looked like a great place to get Hepatitis B if I’m being honest. Later that night I would hang my hammock from a post in the window frame and the whole thing would get pulled right out of the wall, the wood so rotted and the nails so rusty. Then some good news, one of our patients from the day, a woman whose baby had what looked like cellulitis from an infected insect bite, invited us to come by for some tortillas and coffee. I was happy to get the invitation. I had just changed into my pyjamas, but they were field pyjamas, scrubs, suitable for a walk over to a neighbor’s house for sure. I walked out and the rain wet me again. I vowed to just give up on trying to be dry. ‘We roughin it’ I thought to myself. I wondered if anyone else felt as rough about this all as I did. It occurred to me that they didn’t, because to them this wasn’t living rough, this was just living. Spend enough time out here like this and you won’t notice anymore, that would have to be my solution.
We walked out into a rock path, headlamps on. We continued walking, we passed a group of youngins doing youngin things. We went off the rock path. I rolled my pyjamas up to my knees. Again came the mud, my flip flops broke, and I had to do my best to walk barefooted, with extreme caution. There were spines in the ground that could stab you pretty bad if you stepped on them, I had seen a woman in clinic just that day who took a lemon spine (don’t even know what that is) into the foot three months prior, her foot was still swollen and somewhat sore from the trauma. We came to puddles, little streams and slippery logs. Gingerly I stepped. More puddles and mud, with some tree roots to step on peppering the muck. We were walking all this way just to get to her house I thought to myself. This woman wants to go anywhere and she was to walk through all of this? By the time we got near there was a nearby rain catch with a sawed off bottle used to splash water on the feet and rise before walking in. He house was luxurious by many standards, big for the four people that lived there, with concrete floors and a central beam resembling an unfinished basement. I sat wet, with mudstains on my pyjamas. We talked about nonsense for a bit, before the coffee and tortillas. Some of the team asked me about diseases, Alzheimer’s, kidney stones, the interplay between genetics and the environment. We chatted about houses, about construction. There was just one table, in the kitchen, three plastic garden chairs, a wood bench, a hammock and again no lights. Her kitchen sink was a window, three wooden planks forming shelf into the outside world slanted to one side, with a water bucket and a jar of soap. It was something about that whole day, being wet, the miserable sky, the decaying schoolhouse and the muddy walk that made me contemplate the incredible circumstances of these people’s lives. I thought to myself how people read this blog, yet I still think you wouldn’t believe the conditions that they live in unless you saw it for yourself. When I was sitting back in the living area, I felt a sting in my foot: ants, inside her home. I moved my chair and put my feet up like a yogi. Marlon cackled and everyone made fun of me.
‘How come they always come for me?’ I laughed ‘look, they’re just leaving you alone.’
He looked at with a smile. ‘They don’t like Indian blood’ he said.
