The mountain gets cold at night, something that I failed to adequately prepare for, and I froze my little tush off in the hammock overnight.

The hike down the next morning was significantly tougher than then way up, almost exclusively as a result of the battering my right foot was getting through the boot. My sock from day one had essentially been ruined, and so in the interest of sock preservation I made the difficult decision to make the descent barefooted in my right boot. I picked up a couple nasty blisters, and the constant re-introduction of rocks and mud only aggravated this. Not only that, but the sancudos up on the mountain had a field day with my legs after bathing in my shorts, so I was covered in ugly bug bites. Oh and also, the boots were too tight around my calves, so by the time we reached Pueblo Nuevo the rubber had burnt off patches of hair all over my legs. We made it to the rancho sometime just before 11, and trying to not show my discomfort I slipped away to wash and bandage my feet before we got started with the Depo injection clinic.

By this time I was uncomfortable already, on two days of awful sleep, and all my clothes were sweaty as it turned out to be a wicked hot day. My face shield and mask had me feeling like a half-sentient baked potato, drowsily gasping for air and debating whether I was starting to get sick myself. The young women were lining up for their shots which were a crucial part of their family planning. As they came along I banged them out one after the other. Although we were meant to run a quick injection clinic in the morning, things never turn out like they’re supposed to, and as more and more patients turned up I saw that we’d be busy well into the afternoon. As much as Jack fussed to maintain order, I was cognizant that these people wouldn’t see a doctor for three months at the very least, and I was determined not to leave until we had seen everyone.

Again there was a plethora of odd rashes: One gentleman, in his fifties, had a one week history of a full body eczematous rash that itched like crazy. It looked like little freckles, and if he hadn’t told me he was itchy, I would have probably presumed that’s just what his skin looked like. He had seen a number of doctors about it, as he was a more commercialized man with social insurance, but decided also to show up to our clinic and get another opinion. If only he realised how little I had to offer him, which I explained. He had no history of allergies or eczema, nor did he have any recent exposure to plants or new detergents. He mentioned that he had taken some herbal remedies and found that they helped. ‘Stick with that’ I said to him ‘And lather yourself up nice with coconut oil’.

Another patient, a woman in her forties, presented with the most bizarre unilateral leg rash I have ever seen. I asked her permission to photograph it and publish it into DERMNET for some expert opinion. It didn’t have any features that could clarify its origin, she just had occasional itching on only some days, and pain her leg when she walked. I called the boss and he himself had no idea. He explained to me how many people in the communities worked or lived near the banana plantations, and the amount of agro-toxins crop dusted on the fields was immense. He had never in any part of the world seen so many unusual rashes in a population as he did in these places. We agree to trial a steroid cream, on just one part of the rash at first and then see how she got on. That was it. No blood test, biopsies, or anything of the like. I imagined how the western publication machine might gobble a patient like this up, write up novel case for the endless stream, but alas by virtue of her whereabouts she’d get nothing of the sort.

There was one gentleman, a farmer, who showed up early and sat down to wait. He was very calm, and just asked me to come by and take a look at something when I had a minute. He didn’t think it was necessary to check in and register. He let me get through all my shots, and waited nearly all day in the sun without saying a word. I spent hours attending patients sitting to the left and right of him, with a periodic nod to let him know I hadn’t forgotten, until I finally had my last chunk of patients waiting and popped by to see what exactly he wanted. He had a cloth draped on his arm. And then proceeded to tell me he had picked up a cut a week ago with a glass bottle, lo and behold this is what he showed me:

Our friend here had a significant surface wound, the likes of which I had never seen before, especially one like this a week old already healing to some degree on its own. I knew I was going to have to do some real handiwork, and as someone who regularly ditched surgical theatre for the wards, I wasn’t terribly confident in my ability. The boss wasn’t available to chat, in a meeting for a time. I searched the internet as best as I could quickly and couldn’t find anything that applied to my situation. This guy has had been at this for a week now, it doesn’t look infected, and surely by now it would be if it was going to. Do I even bother with antibiotics? I had nowhere else to turn but the original Doctor herself, my lovely mother. I rang her and she immediately ignored my call. Surely enough like I knew it was coming I was getting a facetime from my dad, as they were probably together. The conversation went something like this. Keep in mind I had just spent an extra night in the mountain and she hadn’t heard from me in three days.

                ‘Hi dad can you put mom on the phone’

                ‘Why?’

                ‘Can you just please put mom on the phone’ I said with the attitude of a frustrated son. ‘Also take me off of video because it won’t let me deactivate speaker phone, I need to talk by phone’

                ‘Why?’ he sounded worried.

                ‘Can you just take me off of video and put mom on the phone please ffs’

Enter voice of my mother, whose blood pressure is probably 300/200 at this stage, because that’s what mothers do when you call and need something on your terms right away isn’t it?

                ‘Whats going on? Are you okay?’ she says

                ‘Yes I’m fine, I need your help with a patient’

                ‘Hijo de puta me diste un susto barbaro. Whats going on? Is everything okay?’

                ‘I literally just told you I’m fine mama. I sent you a picture, can you open it?’

Of course there is no such thing as private conversations or private images amongst my clan, so my brother who was also lingering in the vicinity, a 28 year old grown man and self-proclaimed outdoorsman, nearly vomited on the spot after seeing the photo. I gave her the story. My question was primarily about antibiotics, I wanted to give him ciprofloxacin, because of some fixation of mine that it had better pseudomonal coverage than the other antibiotic we had on hand, cephalexin (Pseudomonis is a bactaria that can commonly cause infections due to penetrating trauma, hence my concern). She told me I had it all wrong, Cephalexin was the way to go, give him 500mg twice a day for a week, and don’t do much to the wound, it’s already healing by secondary intention. Just clean it out and cover it up. That white stuff you see there is coagulated leukocytes. Also please call me later; I want to hear about everything that happened, and do that to me again.

Sure thing mama, thank you.

I recruited the help of Chrys and I donned my sterile gloves and got to work. As a team we improvised; I was just applying logical principles and displaying some degree of confidence so as not to look like an idiot. We started by bathing his arm in isopropyl alcohol, like a pintman pouring pints. Using sterile gauze we scraped away all the delicious goodness, trying to clear any residual biofilms on the external surface, applied some antibiotic cream, and then I opened up our steri-strips. Much to my chagrin, they wouldn’t really stick to the cream, and so served not much purpose in terms of approximating edges. I figured their presence alone would at least help to prevent infection. We followed that up with a vacuum dressing, and then taped on some more gauze (we had no rollable bandages, which would have probably done the trick much better). I gave him his cephalexin and sent him on his way. I was amazed at his stoic demeanor during the whole ordeal, the entire time he did not so much as flinch. Some man.

We were staying ages later than we had originally planned, and we had to leave to catch the boat. One captain had already been dispatched, waited for us in Almirante long enough, and left. I was expected back in time to help with Thursday base clinic, and I knew for a fact that wasn’t happening. Jack and Chrys did what they could to help and get us moving, and I waved them off time and time again. ‘We don’t mean to rush you but…’ I understood, but I refused to leave without seeing everyone. We got through it over the next 3 hours were ready to head off around 4 when I realised there was something I had forgotten, that 17 year old girl with the baby from before I left up the mountain. Shit. Thankfully, fortune favoured me and she was turning up to the rancho with her mother as we were already half packed up to go. She had three children with her, and to be honest I didn’t really understand where they came from. I had Jack dig up a pregnancy test and gave it to her while I quickly checked up the kids and gave them their albendazole. I explained to grandma how I had spoken to my boss about them, that despite them only seeing me for fleeting moments they had been in my thoughts. Of course the pregnancy test was positive, so as the last bits of the clinic were getting carried out by wheelbarrow I squatted down in front of her and told her the news.

She didn’t seem surprised, as a matter of fact she didn’t react much at all, which I found quite hard to read. Grandma was really worried. In her beliefs she could no longer breastfeed, this was bad for the baby she said. I had never heard anything like that. I told her that I didn’t think it was, but she insisted. She nearly started crying. ‘I don’t know what we will do’ she said ‘We need money for baby formula, and for a crib. A crib is 19 dollars. The baby sleeps on the floor, it is not good for him.’ Meanwhile I could feel the pressure of the team waiting on me. This poor girl, 17, now pregnant with her second child, the three days I had been through, my feet, and everything else in between hit me all at once. For some reason I thought of my own mother. For some reason I thought of mothers everywhere. I didn’t know what to say. I told them I had to go. On the inside I was falling apart. I reached into my wallet and gave them forty dollars, which I knew I probably shouldn’t have. Such is life. I can’t imagine I’m the first and certainly won’t be the last to crumble under the pressure. Jack had everything packed up and ready to go, but insisted that I eat something before we head out. It was now 4pm. I sat there, looked down and ate, trying to keep it together. I apologized to Jack and he told me nothing of the sort was needed. I hid it well but I had a lump in my throat. It was a lot to take in.

The car ride to Almirante was basically a blur. I was exhausted. We stopped at a gas station and I got some chocolate milk, my culinary sanctuary of choice, and a bag of plantain chips and sat on the curb. I was checking my phone, and had another series of texts from my friend with the UTI, of course he was just being anxious over his health, but for some reason his messages really pissed me off. He was grilling me for not responding to his messages. I snapped at him. He was only busting my balls, I knew that at the time but my frustrated just boiled out of me. I chewed him out via text and he didn’t deserve it. Nonetheless, I got back to base in one piece. I took apart my bag and had a shower, trying to decompress before I put myself to bed, knowing that the next morning I’d begin to digest what the last few days had brought me.