Multi-day clinics had changed a little since I was last here. When I first came around, we were really just trying to re-assemble bits and pieces over time as more people became available. Now, with enough turns of the world to resume normality, we did things differently. For one, the clinic trips were longer, instead of leaving on Tuesday and returning Wednesday, we’d be leaving for Bajo Cedro first thing Monday morning. Travelling first by boat to the harbour town of Almirante, we then loaded our things onto a small bus that drove nearly an hour inland until we reached our destination around 11am.

I remembered this community from my last time around because of its relatively well developed infrastructure. A paved road runs through the village after branching off a winding two lane highway that hugs the coast before riding up the mountains. There is cell phone service, satellite dishes, and concrete buildings with sheet metal roofing in place of the usual plank-wood and straw. The nearby school was undergoing construction, and the sound of power saws and hammers echoed through the rancho as we set up. I was actually going to have two helpers at my treatment station today, new arrivals from the weekend. Jalmer, a Dutch medical student and yoga instructor who took notes on just about every word of advice he got, and Shane, a third year internal medicine resident from Texas with a bubbly smile and clear blue eyes. Shane was in a particularly good mood because about four days before we met, she found out that she’d matched into an Oncology fellowship in California. Not a bad gig…Way to go, Shane!

Getting set up, I took some time to walk them both through the basics of how we receive patients from intake, mentioning some tips and tricks of the trade in the process.

‘Usually,’ I explained. ‘The patient will have intake with vital signs done by the time they get to us, except for early in the clinic when we’re first getting started. This means usually we’ll do the intake ourselves for the first few patients.’

‘Great!’ beamed Jelmer.

After refreshing them both on how to take manual blood pressure and finger-stick glucose (you’d be surprised how many doctors don’t habitually do either of them, especially in the United States), we fired up the tablets and got down to business.

Throughout the morning we saw some real bread and butter medicine cases. Uncontrolled diabetes and the dilemmas of increasing anti-diabetic medications given our limited options and lack of lab work, older patients on blood pressure medication with silent signs their blood pressure was actually too controlled, placing them at risk of fainting due to low blood pressure, and a lot of children with flu-like symptoms (an extension of the monumental spike in viral respiratory infections in children all across the world post-covid). We also got called to a home visit to see one of the most classic presentations in all of medicine that surprised me in its prevalence within this population; a condition called chronic obstructive pulmonary disease, or COPD.

Chronic obstructive pulmonary disease is what we call a reactive airway condition that shares a lot of similarities with asthma, with some exceptions. In order to explain it simply, it’s useful to talk about both of them together. Asthma is a condition in which the immune system becomes hypersensitive to benign particulates in the air, like dust, pollen, or anything small enough to be inhaled. As a result, when these microscopic particles enter the airways, the airways react aggressively like they would if you were inhaling a noxious toxin. In the context of asthma, local chemical signalling pathways trigger inflammation and constriction of muscles that enwrap the small branches of the lungs. This essentially shrinks the size of the airways and brings more immune cells to the area to fight off potential damage. This is why patients with asthma will typically feel fine until they inhale something that triggers a flare, and the resulting airway shrinkage manifests as chest tightness and wheezing, which is corrected with a short-acting inhaler that relaxes the muscles of the airway to alleviate that tightness. COPD on the other hand, is the chain-smoking grandfather of asthma. Instead of being triggered from an irregular immune response, it’s caused by lifetime exposure to inhaled toxins (most commonly cigarette smoking). Over time, the airways begin to suffer permanent changes related to the same kind of inflammation, leading to extensive wheezing that typically produces a chronic cough. Additionally however, this inflammation destroys the walls of the lung tissues that perform gas exchange, we call this destruction emphysema. Emphysema in its later stages can be devastating, as patients fight for every breath they take, taking deep, laboured breaths using not only the diaphragm, but recruiting other muscles of the chest and thorax. Unfortunately, while we can give medications to help dampen the symptoms, most of the damage of COPD and emphysema is irreversible.

Shane and I were guided by our patient’s middle-aged daughter up from the central rancho down a concrete path that coursed around the local school, a small shop, and several other homes. Passing by wandering chickens and little ones in school clothes, we stepped up a small staircase into one of the casitas that stood on the corner of the path. The last time FD had seen this lady, she was really sick. In the midst of an acute COPD crisis, she was struggling to speak in full sentences and couldn’t comfortably sit up without gasping for air. At that time, she was given a letter to take to hospital and blasted with oral steroids to bring down the inflammation. As we came into the casita, a litany of young children were shooed away to one side and the daughter brought out two plastic chairs to sit in-front of the bed where the lady lay flat, turned away from us. Taking notice of our arrival, she turned over. From her appearance she looked likely to be in her sixties or seventies.

‘Hi, I am Doctor Lopez, are you comfortable laying down or would you rather sit up while we chat?’

Begrudgingly, she acknowledged my greeting without verbally responding, and sat up in the bed. Immediately, I could see the heave in her chest and she inhaled. Large, straining muscles expanded her torso and collarbones with every breath. Despite this, she looked comfortable in her current position without any active distress.

‘How are you doing?’ I asked.

I heard her daughter next to me repeat the question back in Ngӓberi before she responded.

‘Good. The medicines you gave me helped,’ her daughter relayed.

‘Is that right?’ I said. ‘Amazing. From what I am told you were fairly sick last time. How does your breathing feel now compared to when the doctors saw you?’

‘Better, better.’

‘Are you able to walk without getting short of breath? Tell me what that’s like.’

‘Here in the home I can walk, but not much. I don’t help with cooking anymore. Down in the community, I haven’t walked at all in many months,’ she answered.

‘Why is that? Do you find your breathing stops you?’

‘I don’t have the energy and get tired quickly,’ she said through her daughter. ‘I also ran out of the inhalers two weeks ago. My cough won’t go away.’

‘Ah yes,’ I said. She had been given two long acting steroid inhalers and a short acting airway relaxing inhaler, both of which should have lasted more than long enough. I wondered if maybe she wasn’t using it properly, which is something that can happen commonly.

‘I have some more for you now actually. I come with gifts,’ I said as we took more inhalers out of the banana yellow gym-bag we were using as our home-visit pack.

In the discussion that followed, I got to know more about her. She was in her seventies alright, and her lung disease controlled her life. She no longer had the stamina to walk around without getting breathless, and hadn’t left the home to walk around the paths through her community in months. Like many in the communities, her lung disease was not the product of smoking, but secondary to a lifetime of cooking in kitchens with indoor fire pits, and regularly lighting smudge fires to clear insects and chitras disturbing the peace. Per the World Health Organisation, indoor cooking fires are one of the leading causes of long-term disability and disease in under-priviledged communities worldwide, with over 2 billion people (a third of the global population) exposed to indoor air pollution on a daily basis. Not shockingly, women and children tend to bear the greatest burden, as the men spend days working fields or doing labour. Here I was seeing the physical manifestation of something I was taught in public health class as a first year medical student but never had the chance to fully understand. To make matters worse, her husband of many years had died a month prior, and so much of our discussion revolved around how she was coping and drawing from support structures in her family to help her deal with it. Also, she had pretty significant wear and tear arthritis of the knees, because the universe deemed that she hadn’t had enough already. Thankfully, we had a few tricks up our sleeves to help her out.

Listening to her lungs, she had diffuse, coarse wheezing all through her chest from top to bottom, with reduced breath sounds at her lung bases. Like I typically liked to do, after examining her, I got her to demonstrate to me how she took the inhalers.

‘Great technique!’ I said

Then came the fun part. After being given a hefty dose of inhaled steroids and airway relaxing inhalers, I listened again with Shane. Despite her wheeze still being present, her straining muscles relaxed before our eyes and her wheezing was markedly reduced.

‘Wow,’ Shane said in her Texan drawl. ‘I’ve never actually done that before, listening before and after the inhalers. So cool.’

‘Pretty neat isn’t it?’ I said.

With that we said our goodbyes. Walking back to the rancho, Shane and I were so engrossed in the case, our surroundings, and the thrill of doing medicine that we walked back the wrong way. It was only thanks to the shouting locals that we noticed and doubled back. I could tell Shane was enjoying getting her hands dirty. Taking blood pressures, sticking patients for glucose, going into their homes to see how they live and teaching them inhaler technique in front of an ogling family of grandchildren was something that modern medicine has stripped from the everyday physician in the Occidental West. She was experiencing the same thrill of agency that I got to experience when I first came out here, that feeling of being welcomed somewhere you have no business being welcomed to and delivering true healthcare to people who need it most and seeing them benefit before your eyes. It brings you back to the essence of why we do this job. It was nice to watch her feel that joy, and brought a smile to my face.

Our visit with that lady wasn’t actually finished yet, because I had actually forgotten something at the rancho that we were meant to bring her. Under the hot sun, I donned my straw hat and hustled back through the community a second time carrying a metal walker up her steps before plopping it down in front of her.

‘Knock knock,’ I said. ‘Delivery!’

Seeing the fancy contraption made the children emerge from places I couldn’t even appreciate, and I unfolded the walker in-front of our lady before attempting to adjust it for her height. I say attempted because I didn’t really get the chance, as soon as it opened up, she placed both palms firmly on the handles and startled hustling toward me, away from me, and seemingly any direction possible.

‘Stop, stop!’ I shouted. Her grandchildren were egging her on, cheering and clapping. I was fighting a losing battle. Finally I intercepted her and adjusted the height to give her a bit more ergonomics. Her and the family echoed endless thanks in my direction, which I gladly took, although the reality was that I was only fulfilling the recommendations of the last doctor that saw her. None of this satisfaction truly belonged to me, but hey, the delivery boy gets some love sometimes even if undeserved. That’s life. I was so moved by the events that I told her about the blog, how I had colleagues far away I wanted to tell about the communities so they could see how rewarding it was to come help. She agreed to take a picture with me. Despite multiple attempts to get her to smile for the photo she came out looking fairly displeased in all of them. I swear she was actually really happy!

Arriving back at the rancho, things were starting to dwindle down now around 3:00 PM. Having spent the morning with Shane, I vouched for her Spanish and ability to see patients on her own without me given how quickly she adapted. Between myself, Shane, and a few other providers we made light work of the rest of the clinic. My largest task actually wound up being helping to re-hang the curtains covering the doorway of the private room for patient examinations after a stiff gust of wind threatened to undermine the concept of ‘private’. By 3:30 we were wrapping up, and the bus arrived for us to pack our gear and head for the next community, Norteño, where we’d spend the night and next two days running clinics. 

After about an hour of wobbling through imperfectly paved roads we came up to a muddied soccer field in-front of a small school that marked the entrance to the community. Everyone, clearly tired but not complaining, mobilised to unload the heaps of medical gear into the community rancho a short 5 minute walk into the community. With everything unceremoniously dropped in the right place where it would stay until set-up the next day, we took a brief pause to huddle and touch base as a group before the evening. Some went to bathe in the river, others decided to do a small workout (insanity), while others chose to do not much at all. 

Come sundown, dinner was ready and we convened in one of the community shops to eat as a group, sharing stories of our many different walks of life that lead us to find ourselves in that moment all together sharing the same objective. Before bed, Fermin even whipped out the Ukulele and we sang songs in the darkness for a time before all laying down to rest.