The following day brought us to the third clinic on our triple header – the community of Bajo Cedro, whom we had missed our chance to service two weeks prior because of the protest. It seemed like one of the most developed communities we had been to. The infrastructure was of concrete and I even saw one or two satellite dishes poking out behind zinc roofing. It was a small community, and one that we could reasonably service in a single day clinic. The morning started dandy, with several chronic medication patients that were actually able to come of their meds after having worked to reduce their dependency through lifestyle changes and herbal teas. It is always a huge victory to remove tablets from a patient’s file for a few reasons: first it means that they have addressed their disease and made changes in their life to rectify things, which is a massive step. Second it reduces the baseline cost incurred on us as an NGO. Third, it just means the patient gets to take one less pill per day, which is the kind of small victory that we strive for. The less medications the better. Always.

I picked up my last chart before taking a break for lunch and called a woman’s name. Her appearance caught my eye right away. In her late fifties, she wore a bandana on her head, with mascara, loud earrings, and a nice looking outfit. She seemed like a sassy divorcé, or the kind of woman who carried around crystals that channeled psychic energy. This lady held no subtleties, and she stuck out to me right away because at first glance I could tell something was wrong with her thyroid.

The thyroid gland is a collection of hormonal tissue at the front of the neck that produces a compound called thyroxine. Thyroxine is kind of like the coal that keeps our physiological furnace running, it modulates the metabolism of our cells. Too much thyroid hormone creates a surplus of metabolic activity, people run hot and get sweaty; they start to lose weight, and their heart beat accelerates, sometimes entering abnormal rhythms. Thyroid dysfunction being more common in women, sometimes they stop menstruating and their hair begins to thin. Inversely, if the thyroid becomes underactive the opposite happens, the weight goes up, people put on layers and layers yet still feel cold, they get constipated. This woman looked like her thyroid was probably running at one hundred degrees Celsius.

She just had that hyperthyroid look. Her thin figure, the colour in her cheeks, the undertone of anxiety in her voice. Her hair was pulled tight against her head, and her forehead had a shine of sweat. It’s a difficult look to describe to someone who is not a medic, and sometimes it’s not so much a look as it is an energy. I was once taught by a music instructor that it’s not those things that you hear, but those things that you can feel that set apart one performer from another. I think that clinical sensitivity is likely the same, sometimes there are things that words cannot describe but one person has learned to detect. She was also trembling, and I noticed it in both her hands and in her head. Tremor classification can get messy and convoluted, but here are the basics:

Generally speaking, tremors, i.e. ‘the shakes’, are caused by activations of the central nervous system, in particular the adrenaline based networks of fight or flight. They can be classified into two broad classes:

• Resting tremors – involuntary high frequency shakes of a body part that is completely at rest
• Action tremors – involuntary high frequency shakes of a body part while performing an action, these can be further divided into
  • Postural tremors – when assuming a certain posture
  • Kinetic tremors – performing a physical action like reaching for something
  • Isometric tremors – during muscle contraction like making a fist or squeezing a ball

There are many different tremor manifestations that can have only one or a combination of the physical tremors described.

Resting tremors are most commonly cause by Parkinson’s disease—which is a dysregulation of neuron firing due to excess of a neurotransmitter called dopamine in a part of the brain called the basal ganglia, and it gets its name from the man who first described it.

Action tremors are much broader, and the most common are the physiologic tremors, which are the normal shakes that anyone might get if they are nervous, startled, drank too much the night before, or haven’t slept well—these can be alleviated by a downregulation of the nervous system, like taking alcohol or medications. This is why some concert piano players or musicians are rumoured to take the heart medication beta-blockers before going onstage. It is also why some professional darts or billiards players claim that they shoot better after one or two pints of beer, as it calms the nerves and reduces associated tremors—The second most common action tremor are harmless essential tremors, that some people have all the time performing any action. These tend to happen as people get older and run in families, and can be treated with the same medications that we give for hypertension. Perhaps the most concerning of all tremors is the intention tremor, which increase in severity as the patient approaches the target they are trying to touch with their hand. They indicate some kind of neurological dysfunction because they are commonly cause by a disruption in the function of the cerebellum, one of the prominent parts of the inner brain.

The lady sitting across from me had a significant tremor in her whole body. So much so, that looking her in the eyes I could see her head wobble, and when asked to hold her hands in front of her, I placed a sheet of paper on top of them and it quivered like a feather in the wind. When I asked her to open my water bottle and put the lid back on, the tremor remained the same without changing. Thus she had a both a postural tremor (holding her hands out), and a kinetic tremor (when taking the lid off my bottle).  

I started to take her history and she described a story that was fairly classic for thyroid disease. For the last two years she had been losing weight and couldn’t understand why. She was exhausted most of the time and was having hot flashes regularly, with irregular periods. She struggled to sleep for more than 4 hours a night and felt like her heart was always racing, with a blood pressure that was soaring when I measured it. When asked about the bandana, she told me that her hair was getting thinner. The history was one that I had read in cases a hundred times over in my training, that it was almost difficult to do my due diligence and explore other potential causes for her symptoms. There was the possibility of menopause of course, but that would only explain the hot flashes and little else. With regards to her blood pressure, she told me she was hypertensive for the last five years, and had been getting medications from a hospital one hour away until she stopped going due to covid. When I asked her about the tremor, she said it had been there for a while and usually resolved when she regularly takes her blood pressure tablets. Still, none of it was enough to convince me otherwise. The thyroid examination is not my forte, and I commonly flounder to find the thyroid with any level of accuracy when practicing. Feeling her neck, I found it right away, which told me that it was probably too big.

I went to find Nicole, presented her case, and asked her to examine the patient’s thyroid since I wasn’t sure about my findings. She agreed, and we referred her to go to hospital to get bloodwork done.

Despite it seeming like a victory on paper it didn’t really feel like it. Sending a patient to present to hospital in search of very simple bloodwork is not something I like to do. Especially in pandemic times, I always worry that we are sending them to get ignored, even if they bring a letter. I just wish there was a better way where we could be surer that they will actually get seen. That’s something that only experience will give me.

Either way I had to set my thoughts aside as I saw more patients. There was one man in his fifties who suffered from pulmonary fibrosis, which is like scar tissue buildup in the linings of your lungs. He came down from his farm up in the mountains where he worked, which at first didn’t make any sense to me considering his diagnosis—Lung fibrosis is a damnation I wouldn’t wish on my worst enemy. In its late stages every single breath is a struggle, people live in a state of oxygen starved suffering, losing weight and turning blue as they slowly decline, sometimes over many years and sometimes quickly. I would rather die of any form of cancer that pulmonary fibrosis—this man was doing so well because he was taking chronic steroids, which is not something you should ever do; the side effects of steroids can be highly damaging long term. He knew what he was getting into though, having been counseled about this dozens of times over by our previous medics and the specialist who first put him on that treatment as a short term remedy. You had to respect that he didn’t give a damn about the long term consequences, although he knew them well. He wanted to live suffering free now, working his farm and making the most of himself while he still could. After his specialist stopped supplying him steroids, he started going out to pharmacies and bought them himself with whatever money he could. We simply provided him with calcium supplementation (protection from the effects of steroids on the belly and on calcium depletion) and inhalers to ease his shortness of breath. He was probably the sickest patient I saw that day and wasn’t really at that sick at all. As a matter of fact, as we were leaving, I realised that all three of our clinics that week were completely manageable, which somehow didn’t feel right. Something about it all felt a bit off.

Obviously a lot had changed. We had a new lead medic for one, for second though, our messaging on site had changed. Due to our budget crisis, were now no longer the ‘here to help everyone’ kind of clinic. We were the ‘here to see who we came to see’ clinic, and I think that message was being received. My concern started like a tick sized splinter in my brain and over time became an ever-present migraine. I knew there were people in these communities that had serious things wrong with them who were getting turned away. I had seen it myself over the course of the last eight weeks; how many people did I see that were not on our chronic patient list with something serious wrong? All the shy women with subtle abdominal pain and discharge that became pelvic inflammatory disease, farmers with soreness on walking that turned out to be hernias, the lady with chest pain who had a breast mass, the other who just felt tired and turned out to have a heart valve problem, the list goes on and on. We were leaving those people behind. That hurt me a lot. It’s the sad reality of this kind of humanitarian work. There will just never be enough to go around. That was the hardest part of the job, and it was something I expected to find here but still wasn’t prepared for.

Knowing what should be done, and knowing that we couldn’t do it, was unlike anything I had encountered in my training before. I had always been taught in school to think without limitations, to make the best medical decision based on thousands of pages of medical knowledge. ‘Do everything that should be done’ was the name of the game both in education and in assessments. The US medical licensing board certification exams with my colleagues became a running joke, we’d always say ‘Don’t answer the question with what you would actually do, pretend you are the prototype human being they are trying to sculpt and select the answer they would choose.’ Medical exams are not written for real people, they are written for fictional characters inside a computer simulation, where all things are attainable and the imperfections of human interaction and healthcare structures don’t exist.

My flesh and blood computer simulation quickly turned into a survival video game, because when we got home we were met with concerning news, at least for Jack. Max the Kinkajou had been on a tirade of madness all week. Every time he was locked into a new enclosure he escaped. The new cage that was built for him turned out to be an utter disaster, as he found different ways to dig out from underneath or bite through the wire meshwork that kept him inside. Anselmo was left with no choice but to lock him in the toolshed and lock the door. This seemed to work at first, until Max started drinking all the solvents for the power tools, which only made him stronger and more brazen. Finally during the week, one of the rooms of the bunkhouse was converted into a makeshift cage, with steel wiring covering the usual mesh that he was now so accustomed to eating through. At night he would taunt the night watchmen, flicking the light switch on and off just to let us know that he was plotting. During one of his many escapes while we were away, he broke into my room and pooped on my bedsheets. Anselmo told me that he found him sitting on the floor next to my bed chewing bubblegum that he ripped out of a pack on my desk. Clearly he knew my scent, and I found myself facing the dilemma of what to do if I came across him in the night and we met in a Mexican standoff.

Option A) Just be friendly and let him lick my toes.

Option B) Assert my dominance and meet him face to face until he backs down.

Option C), which came to me as I watched his shadowy silhouette inside the bunkhouse one night after too many margaritas: I could strike pre-emptively, open that door and sleep in there myself as if he didn’t exist, showing him who I was and that I had no fear.

I wonder where that question was on my licensing exams.