Forecasted rain was nowhere to be found, and the large cayuco cruised out on bubbling water under blue skies. Amongst the many ins and outs of the bay, we passed under a broken rope bridge that marked our crossing through Isla Tigre, one of the other villages that we serviced. This was a detour, a decision taken by our captain, to avoid hitting larger swells on the other side of the island. His decision prevented risk of the boat tipping, but it also meant that we arrived nearly an hour later to Cayo than anticipated. Considering we were not doing an overnight trip this time around, I would have bet everything I had that we’d run into trouble trying to get everyone seen in time before our scheduled departure at 330. It also didn’t help that the first patient I saw had a very complicated history.
When I got her chart it indicated a long journey, starting in March 2019. At that time, she had significant abdominal pain and was found to be anemic, and a general examination revealed a huge mass in her abdomen. She was evacuated, first to the nearest town of Almirante, then Changuinola, before getting an emergency airlift to Panama City. Imaging at hospital revealed a massive ovarian cyst—so large in fact that it was first mistaken for a tumour.
Ovarian cysts are fairly common, and can be totally benign in most cases. During the process of ovulation, an egg is released from the ovarian follicle, a little bubble that bursts open. Sometimes, for a myriad of reasons, the bubble doesn’t burst and remains there. Most commonly they shrink down and go away, and we often times see them as an incidental finding when doing scans for other things, but sometimes they can keep growing and stay there for good. Depending on the size, they can cause pain, or compression of other structures. Usually it’s simple enough to get a needle in there to drain it, but the real danger comes when the cyst is large enough to cause the ovary to twist around its blood supply; this we call ovarian torsion, and it is a surgical emergency. Our lady here had a cyst so big they couldn’t drain it safely anywhere except the most advanced facility in Panama – she had a cyst filled with eight litres of fluid.
Due to our inability to access highly detailed hospital notes from inpatient admissions, the details of her clinical course were murky. We knew that somewhere along the way she developed pancytopenia, which is when the red blood cells, white blood cells, and platelets in your blood are dangerously low. After her surgery and subsequent recovery, he had been battling anemia for the last two years. We were seeing her as a chronic patient, supplying her with iron and vitamins to boost her red cells. She came to me with a new set of complaints however, fatigue, and shortness of breath on exertion, as well as abdominal pain when lifting heavy objects. The fatigue and shortness of breath was almost certainly a symptomatic manifestation of her anemia, but the abdominal pain could have been any number of things.
Considering she had pelvic surgery I asked her about menstruation. She told me it was wild ever since her surgery; she was still regular, but bleeding way more than she used to. I would wager this was the source of her lingering anemia, because otherwise she had no vaginal, urinary, or GI symptoms of note. I did an exam and tried to rule out the most obvious first: she had no visible hernias or palpable masses where she had the pain. Getting her to perform maneuvers that increased pressure inside the belly produced pain, which was consistent with her history. Examining the rest of her revealed signs of anemia in her face (really pale ‘conjunctivae’, the tissue surround the eyes beneath the lids), and she had a significant heart murmur. Again, both of these were likely symptoms of her anemia. Either way her whole case was so convoluted that it warranted an opinion from the lead medic in charge. I waited for an opening she had between jobs and presented the case to Nicole.
Her opinion was right where I expected it to be, this patient had to go to hospital to be followed up by a specialist. She hadn’t been reviewed once since her surgery, which warranted a consultation as it was. There was only one problem: she didn’t want to go.
Sitting across from her, she didn’t seem thrilled at the suggestion, and immediately took a confrontational position. ‘How do you expect me to go to hospital?’ She said ‘I have no money. I do not have a boat. I have children. I cannot go. Give me tablets’. We weren’t in the financial position to offer anyone money for transport anymore. Relaying this to her was not easy.
The conversation got a bit tense. I can understand her position. Imagine being told to do something that you cannot do, it’s like being backed into a corner. She was almost angry. I tried to divert the source of her frustration away from us and place it somewhere else.
‘If you choose not to go that is up to you. I will not force anyone to do anything.’ I said. ‘Please just understand one thing… This is not meant to be a debate, it’s meant to be a conversation. It is not us against you. We are here to serve your interests, and I want us to work together. We are on the same team.’
‘There is no way I can go to hospital. I have to take care of the children.’ She huffed.
She was going to make me work for it. Good thing on this morning I had a lot of patience.
‘Do you know anyone who has a boat? I know there are people here with boats.’ I said.
She didn’t answer.
Nicole and I sat with her a while and did our best, really. ‘We want you to feel better’ I continued ‘Just understand that. I know you want to feel better as well. This is not about anything other than you getting better. The pain in your stomach, the shortness of breath, you have told me yourself that it bothers you. This noise we hear in your heart. We just don’t have the tools here to really cover all the bases that should be covered.’ This went on for a time.
In the end she agreed to take the letter I would write her, although I think it was an empty gesture on her part. I don’t think she’ll go until something happens that forces her to. Keep in mind she had a cyst that had to grow to eight litres in size until it was discovered, and that doesn’t happen overnight. Some people are like that. What more can you do?
As we were wrapping up with her I had an idea. We could give her a depo injection. This in theory would decrease endometrial shedding during menstruation. If she was anemic because of her heavy periods, the shot help correct her anemia. I ran it by Nicole but she didn’t like the idea. I understand why. Giving her a tangible treatment likely presents to her more reason not to go to hospital. On the other hand, knowing she likely won’t go anyways, it would potentially help with her bleeding. Could it do more harm than good, medically speaking? Probably not. Socially speaking? Debatable. In this case, for me, the right decision is the one your boss tells you to do. After seeing her I moved on, happily knowing I spent 60 minutes with the first patient of the day. I love falling behind.
The problem with falling behind is that then you’re in a rush. Nothing good ever comes from being in a rush. You might not be cutting corners, but you trade your charm for speed. The next patient I saw was an older lady getting her diabetic tablets renewed. Like most patients she also had some aches and pains that she wanted to run by me. She had a pain in her knee, which in a lady like this, 99 times out of a hundred it’s osteoarthritis, or ‘wear and tear’ joint pain. One time out of a hundred it isn’t though. I asked my usual questions with an emphasis on speed. Open ended questions went out the window.
‘Just the one knee?’
‘Yes’
‘Worse with walking?’
‘Yes’
‘Does it hurt in the mornings and start out stiff for a long time?’
‘No’
‘Swelling or redness?’
‘It’s a bit swollen’
That’s when I actually looked down at the knee and rested my hand on it. She was right. It was a bit swollen. This can sometimes happen with osteoarthritis, but not usually. It also felt a bit warm.
‘How long have you had this for?’
‘One week’
‘One week?’ I asked ‘No pain before that?’
‘No’
‘What happened one week ago?’
‘Nothing really’ she said ‘I was getting out the hammock. I moved too quickly and I felt something, like a pull. Then my knee started hurting. It has been very sore since then and I am finding it difficult to walk.’ Yikes, not a good sign. I think this woman may have torn a ligament.
‘Has the knee felt unstable?’ I asked. ‘Does it wobble when you walk?’
‘I am not sure.. Maybe?’ She answered
I tried to persuade her to follow me to the private room so that I could examine her knee properly, lying flat, but she insisted otherwise. She was an older lady, and fairly cryptic, so when I probed her as to why, she didn’t give me a clear answer. I think she wanted to be spared the pain. Either way I had to work with what I had, so from her seated position I started examining her knee. Being mindful of her pain, I first assessed where and how the swelling was manifesting. It was swollen yes, but not by a significant margin like the kind you might get with something like bursitis—which is when a bursa, which is a little pocket of fluid near the joint space, ruptures and leaks into the surrounding tissue. Those cases commonly happen after physical trauma and patients watch their knees go from normal to melon-sized in the span of hours—Furthermore, the swelling was localized to the front of the knee, around the joint line, as opposed to in the back above the calf where it might collect if you had a baker’s cyst—an anatomical fluid filled sac that can develop in the hollow space behind the knee. It gets its name from a British Surgeon who discovered it. Sometimes, similar to the bursa, they can explode with trauma, and leak fluid down the posterior compartment of the leg which collects around the ankle producing a classic ‘crescent sign’ which I have only read about it books and never seen—She also had pain on flexion and extension of the knee, both when I moved her leg and when I asked her to move it herself. Having only had her trauma around one week ago, it was possible that she had something like a bursitis that was now shrunken down and resolving, but only sophisticated imaging could definitively say what was going on. No chance in hell she was getting an MRI though, which would be the standard modality to assess the status of her ligaments.
Amongst all of the ligaments that make up the knee, there are specific clinical tests that can be done to appraise each one. I began testing the laxity of her collateral ligaments, on either side of the knee, always making sure to compare the afflicted side with the non, and the ones in her sore leg felt a bit looser than the other. Next I moved on to what we call the drawer tests, which give us the status of the cruciate ligaments, the anterior and posterior (ACL and PCL) which form a cross and anchor the tibia and the femur directly onto one another. Again, I felt some laxity, particularly in the ACL.
The thing about ACLs in particular, is that they can behave oddly when injured. Some people can tear them without even knowing it, discovering it incidentally when in physio for something else (my own personal story). Others might experience a sound like a shotgun going off and then collapse onto the floor in overwhelming pain (something that I witnessed first-hand during a soccer game in high school). Some people get really significant instability, requiring surgical repair and others can play full careers in sport without one altogether, putting off any repair until after retirement to avoid severing it again. When it comes to trauma, a blow to the knee while the leg is planted places you at risk for the worst possible outcome, what we call the unhappy triad, which is a tear to the anterior cruciate ligament in combination to the medial meniscus and the medial collateral ligament.
I thought this woman had ligament damage, based on my laughable clinical savvy and four weeks of orthopaedic seasoning. However, the associated reality was that I could do exams to the moon and back and it wouldn’t really change anything. There wasn’t much we could do except give her a support brace, some pain relief, and see how this evolved over time. If we came back in three months and she was still, crippled with pain, maybe we could consider getting her seen by orthopaedics somewhere very far away, and she might wind up on a multi-year waiting list for an MRI. If she played for the Toronto Raptors she would have been seen, gotten imaging done twice, had surgery, and given a full physio plan a dozen times over by now. Hard luck.
The day went on and patients came and went as they usually do. In a surprising turn of events, we finished on time, which in my eyes was not a victory. I knew there were sick people in the community that didn’t show or were turned away. Packing everything into the boat gave me none of the satisfaction that it used to give me. On the boat, sunshine soaked my face as the cayuco bobbed up and down, and I was left to stew.
What should have been an enjoyable journey just irked the crap out of me. It irked me more because I felt like we could have done more. I didn’t like heading home at 3pm, it provided me no pleasure. What the heck was I going to do at home anyways? Nicole and I found ourselves having the same ruminations in parallel, and we agreed to hold onto it and bring it up at the next staff meeting on Friday. I was glad that we felt the same way. How could we not though? If anything, it would have been messed up if we didn’t. Still, we managed to fill the time chatting nonsense and she grilled me with loads of questions in preparation for my long case exam. With all the other things swirling around my head that exam was the last of my worries. Again we passed the broken rope bridge, which never felt more relevant; its frayed ends encompassing the disconnect between capacity for care and need.
I get the impression that someone decided that there was no point left in fixing it at all.
