Her mother follows silently and enters the room behind us. We sat down in the dark. I took off my headlamp, and using a plastic bag I found lying around, cover it, casting a dulled glow. I am wearing my face-mask and purple gloves with a face shield, too big for the room around me barely lit, looking like Shrek in that scene where he sneaks into the potions factory. Somehow I’m expected to get through to a sixteen year old girl from a completely different culture on the details of her sexual activity and genital infection. Good luck.

I ask them what I can do. Mom says her daughter has a cold. This is a bit odd at first but I don’t react. The girl asks her mom to leave and close the door. Now it’s just the two of us behind closed doors, which immediately makes me nervous, I want a chaperone but realise quickly there is no chance of that happening. She barely talks. I ask her how she’s doing and she says she’s okay. She’s petrified with shame, and I can’t really blame her. Shrek tries his best but gets nowhere. I may as well have had a talking donkey; it would have cut the tension. After a good while of sitting tensely in silence she begins to talk, barely a whisper. I can’t hear a thing and decide I need to ditch the shield (apologies to my mother reading this). She begins to tell me about how she had relations with a boy she didn’t know too well, around a year ago. She got sick after, really sick. Wound up in Changuinola hospital for a week. They told her there that she had herpes. She was scared. She told me she had gotten better and now had lesions down below, and they were sore. I thought carefully about my next words, knowing that I was on the precipice of being let in or completely shut out. I spoke.

               ‘Tell me first, what do you know about Herpes?’ I asked.

I was taught this during my time in the Lourdes Hospital in Drogheda, it’s a good way to determine the baseline for a consult, found out how much she knows and where we need to start. Sometimes patients come in for cancer results without even knowing the test was sent in the first place, sometimes they know exactly what the news is going to be. It’s hard to tell sometimes who you’re dealing with.

’Nada’ she replied. Okay then, I thought. Let’s start from scratch:

Herpes, believe it or not folks, ain’t really a big deal. Honestly. It is chronic and never goes away forever, but the worst infection by far is the first. That is the sickest you will get, generally. After the first infection, which can range from painful but benign lesions on the genitals to full blown meningoencephalitis (a devastating infection of the soft tissue of the brain and its surrounding lining, at times fatal), you’re past the worst of it. The worst thing about genital herpes after is the stigma and the emotional baggage that comes with it. I met a woman once, outside of the medicine, who struggled to find relationships because the fear of rejection was so cataclysmic she never saw herself finding anyone that would accept her and her disease. I counseled this sixteen year old in-front of me about how the disease course evolves. You will be completely fine for periods, there will be no lesions and no pain down below, business as usual. At times it will flare, and when it does most people do nothing about it as it goes away with time, but if you want there are antivirals that can be taken during outbreaks to make them chill out. After talking to her for about five minutes straight, I asked her if she understood. We sat in silence for a moment, and she started crying. I waited for her, and after a time she stopped. I tried asking her again, and again she gave me nothing. I had to try a new approach, and I was making it all up on the fly.

‘How about this’ I said ‘why don’t I ask you some questions?’ ‘Herpes, is it serious, or not that serious?’

She just looked at me like the Shrekish moron that I was

‘No really, tell me’ I said. She shrugged.

‘The answer’ I said ‘Is that it’s not that serious’ and I repeated much of what I had said already but now under this pretense. The first infection, it lies dormant, the flares. You will still live a normal life, you will still have kids.

’Now I ask you again. Herpes, is it serious or not that serious?’

‘Not that serious’ she said. Right, I thought. This is crude but I’ll take it.

‘Why isn’t it that serious?’ I asked. Again she shrugged, and again I explained to her the dormancy, the flares, and the lack of real threat to her health.

‘So explain it to me again’ I said ’Why is Herpes not that serious?’ With her answer I got what I wanted, which was just her to have some understanding of the condition. I was going out on a limb here and assuming that the hospital where she was first treated had run a full STI panel for other diseases, and knowing she had probably endured enough of my pseudo-counseling, I left it at that. I asked her if she was still active and she said no. I offered her condoms and she said no. I offered to do an exam on her to have a look and reassure her and she said no. I offered to facilitate a discussion with her mother and she declined that as well, although her mother knew. I had to take all of the above as a victory. Or maybe it wasn’t, maybe she hated me, and got nothing from the consult but I did my best. It was such a strange patient encounter that I even spared her of the ritual, the first time ever in the Panamanian Islands I had done so willingly.

My day wasn’t over yet, I still had one more house call to make, and this one was shaping up to be a deusy. It was a woman I had talked to during the day. She told me she suffered from episodic chest pain, palpitations, and shortness of breath, with sweating, blurring of vision, and a general sense that world was ending when these episodes happen. There are two main differentials that jump out at me right away; guess what they are. Now factor in that she’s twenty eight, and her infant daughter died within the last year, which sent her into a state of depression (how could it not?). Believe it or not, she came to me asking for Aspirin. A doctor somewhere else had put her on it and now she had run out. This is where things get tricky as a medical practitioner, especially so as a medical student who is not yet actually qualified.

It is hard enough to have a difference of opinion with another practitioner, but come on. Her cardiovascular exam was normal, and I refuse to believe that a 28 year old woman with this history has coronary artery disease. I will die on this hill, angiograms be damned (I’d bet the house she never got one anyway). I told her, very subtly and diplomatically, that I would not be renewing her prescription of Aspirin, and then I asked her what she knew about panic attacks. Even with that diagnosis, the real question now becomes what I do about it. I asked her to tell me where her house was and I offered to come by in the evening. I am not sure what I intended to do there, I just knew that it involved a longer conversation in a more appropriate setting. Small towns being what they are, everyone knows she lost a child already I am sure, it might even be common enough, but I didn’t want her to be made vulnerable with dozens of leering eyes in distance. So here we Jack and I, me playing psychologist for the second time that evening under the cover of night and rain, walking with my umbrella searching for the right house.

I finally found the place and she let me in. Jack waited outside, she was home alone, her husband and other child a neighbor’s, and we started chatting. She seemed uncomfortable, in pain, and not really interested in our discussion. I realised that she was in quite a lot of it. I got her onto a bed, which made her wince. The pain was in her abdomen. I felt around but all I got was fat, like many of those that wound up in our clinic she was overweight. She doubled over in pain, sweating profusely, almost as if in labour, and I tried to coax something of a history from her. She said this happened often, most nights even, and she didn’t want anyone to know. ‘I am always in pain doctor’ she told me ‘I put on a face for everyone because I don’t want them to pity me, but I am not okay. This happens every night.’ I had no idea where to begin, it was a diffuse abdominal pain, I asked her about bowel habits, and she had periods of constipation, sometimes going three or four days without defecating. That was the only thing of substance in her history. She must be blocked up I thought to myself. I felt around for a fecal mass in the abdomen but felt nothing of the sort. I was starting to get worried, I debated whether I should treat this as acute, start running it like an ED case, but after a little while it seemed to subside. She sat up from the bed, and seemed okay.

To be honest there was too many things hitting me at once, I figured our discussion about stress and panic disorders would have to wait, because she seemed to be in so much pain the very act of conversing was an annoyance. I told her I would hurry to the rancho and bring her some things I thought might help. What I wanted was a stool softener and some paracetamol, just to get her through the night. I wanted to give her some relief so that she felt cared for, I had to give her something to gain her trust. When I went back to the Rancho I found we didn’t pack the stool softener in the pelicans, and turned up to her house with only one of my promised pills. So much for building trust. I told her to come back the next day and tell me how it went, if it gave her any relief, and she nodded. I walked away from her house knowing that there was so much more to her than what I’d get the chance to address in my tiny stint here. I sighed to myself as the rain pattered my umbrella.

Getting back to the rancho I was tired from the day, but still in decent spirits. Our bathing situation wasn’t the greatest, just a bucket of water and bowl in a nearby kitchen that had been left open for us. I got myself cleaned up, and it was closing in on 930pm. I pulled a plastic chair out from the rancho and sat next to the school in an open clearing of grass. I got lost staring up into the sky. I pondered for a moment the insanity of my situation. How the hell did I get here? We saw 25 patients today, in one day. Surely there’s no way we can match that total tomorrow I thought. We had decided our last possible departure to be 1pm, before the tide dropped and the cross winds make the exit from the river mouth impossible. We were going to be tight for time, I knew that much. Despite this challenge looming, and precious minutes of rest melting away, something compelled me to stay out there, sitting in silence. My mind went empty for a time, I’m not sure how long I sat out there ruminating silence, but it wasn’t until long after the youths had scurried home that I finally crawled up into the hammock. If I’d known then how our exit then next day would actually pan out the next day, I would have gone to sleep a lot sooner. I’ll tell you that for free