Tuesday morning rolled around just as expected, and also as expected I was well enough to motor but not yet fully me. Despite my lingering illness and the soul-crushing disappointment of having lost my stethoscope that very week, I would have to make do with the bargain bin equivalent of both myself and my equipment. Feeling 100% ‘with it’ is inconsequential to the life of a medic I have learned. ‘Anytime someone offers you the chance to eat you take it’ I was once told in the ICU, ‘even if that means eating your lunch at 10am’. Although sleep had not been my biggest ally over the last week, I knew that all things being considered I would never do a 24 hour call, or perform a seven hour surgery here in the middle of the swamp. Working hours were reasonably respected while I was on base, despite the odd appearance of sick people after dark, something that had happened only once in my first month here.
Deployment was another issue entirely however. I had become accustomed to treating patients in the dark, being asked by every Tom, Dick, and Harry for an opinion while walking to eat and back to the Rancho, or even during consults. Picture this: you are in the middle of auscultating someone’s lungs when you get a tap on the shoulder. Who could this be, disturbing my ritual, by god it must be important, you think to yourself. Your sphincter tightens. The earth stops spinning on its axis, and for a brief fleeting moment every dog around the world stops barking. You turn around. It’s a man, not even an important looking one, or a woman, her body bursting against the traditional dress that houses her, being followed by gang of her little crony grandchildren.
‘I have a pain in my leg’ she says to you. This pain is the most important thing on the planet right now. It is so bad that she appears to be standing just fine in-front of you. By golly you must be careful not to let your exasperation be seen out here in broad daylight. Not in front of all the kinds.
‘Go to the table over there and register’ I say. By the time she walks away I have forgotten everything about her, but one of her cronies lingers still, just watching. The cronies never leave.
This week provided a different flavour in our setup; we would be bringing a committed four person crew this time, and slightly modifying the structure of our operations. Jack was the commander in chief, sorting out the details of travel, food, and planning, all while acting as the order-giving boss for tear down and setup. Sam would be joining us and splitting the registration duties with Jack, as well as doing the bulk of patient intake. Marlon, who served usually as captain was going to be our pharmacy manager, which meant that he’d be the one in charge of making the medication bags after I saw the patients, something that would massively ease the time burden on me.
The first test of our squad happened before we even left. Our plan for the week was thrown in the chipper, as there was a protest that obstructed travel between the two communities of Bajo Cedro and Norteño. Our plan to travel to Norteño from our closest port on the coast would have to be re-routed, meaning that our initial travel time of 45 minutes became a 1.5 hour boat trip followed by a one hour drive around the source of the turmoil. We arrived at Norteño two hours later than anticipated. The Rancho we were meant to use for clinic was occupied with another gathering, so we had to relocate to a different spot in the community. Usually, when we set up clinic, we have existing relationships with the houses nearest by in case we need private rooms for assessment, or someone to keep an eye on things while the team is dispersed. It even makes it handy to know who is around because we often sleep in hammocks in the Rancho during the night. This would all have to be worked out on the fly.
Our setup took longer than usual but soon enough we got things going. This community more-so than others has one of the largest burdens of chronic disease, with more diabetics and hypertensives here than anywhere else we went. Combine that with Norteño having the largest population of all our communities meant that the majority of the work was in basic appraisal of the numbers. For the first time during my elective I felt like I was doing what we are actually supposed to be doing, which is chronic disease follow up exclusively, making sure our diabetics and hypertensives aren’t spiralling out of control. Monitoring is the key
‘Hello so and so, how are you getting on today’
‘Fine. I get the odd headache though’
‘Interesting, I would love to hear more about that, but first very quickly tell me, how long have you been out of your Metformin for? Your blood sugar is really high.’
‘I still have them doctor.’
Hmmm…
This is never a good sign, the bane of chronic disease is progress, and that is exactly what we are trying to avoid. Every time we need to up the dose it’s another nail in the proverbial coffin of living a life that is controlled by you, not your disease. Luckily in these moments I had a secret weapon.
‘Okay right. Still have the tablets, now tell me: Did you take your metformin today?’
‘No I didn’t doctor’
‘That’s okay then’ Crisis averted. I didn’t have to be the one to discover that they were trending in the wrong direction, at least not today. ‘I’d expect your blood sugary to be high in that case. Just make sure you take it next time before we see you so that we can accurately gauge if our treatments are doing their job, otherwise we may need to change things. Now tell me about that headache…’
Of course sometimes they had all the right answers, they took their meds, knew the details of their condition, and still could not get it under control despite haymaker after haymaker of medication. It’s especially hard when they seem like motivated, educated, and generally great people. I know as doctors we are meant to treat everyone equally, and of course that’s what we try to do, but humans are only human. I met one gentlemen just like that later in the clinic.
He was a cowboy. Old school, with the hat and the boots, the tough jeans and leather trimmed jacket. He was unlucky to show up after the initial horde of registration right around noon, which doomed him to a full day of waiting. He came up to me between patients at one point and asked how long he would have to wait ‘I just want to know if I have time to go and feed my horses. I live very far, which is why I arrived here so late.’ ‘Come back in an hour’ I said. What I should have really said was come back in three. Still, when he returned, he waited patiently without a peep. Even when I took a lengthy hiatus to teach Sam how to give Depo injections and coach her through a group of ten, he waited patiently. I told him he could probably go home and come back again in another hour, but he opted to wait. I always give the same spiel, ‘we’re under resourced’, ‘covid’, ‘I recognise that it’s a full day lost for you and I am sorry.’
‘Not at all’ he answers ’Look we’re all just happy that you guys are here. It’s better than if you weren’t’. I was now almost six o’clock
I decided that Sam, who has just learned that how to give intramuscular injections, could handle the last few on her own, which gave me the chance to sit down with him. He begins by asking questions. He has concerns, his brother who is very close to him was just put on insulin. His brother has had diabetes for seven years, whereas Cowboy here has had it for fourteen. ‘Will I go on injections?’ he asks me ’I find that very frightening. What makes a person have to go on injections?’
Suddenly I get interrupted, its Sam, one of the Depo patients who she just injected is bleeding from the site. Sam is really worried and so is Jack. ‘Oh my god she’s bleeding’. All the sudden movement triggers me to leap out of my chair and quickly jolt towards them both while my patient is mid-sentence. It’s a tiny speck of blood, the normal amount that you can get after a deltoid injection. The fault here was likely my own, not explaining properly to Sam that sometimes they bleed and sometimes they don’t. I turn around and our Cowboy is sitting there calmly with a smile on his face.
We talk for a while about diabetes. I find it really important for patients to understand why we are doing the things we do. Especially with hypertension, telling someone to take tablets that will make them feel no different at all can be a tough sell. This is something I always stress, I give the analogy of too much pressure in the pipes of a house; the water runs fine in the tap for many years, until one day they burst. ‘We just want to bring the pressure down inside the pipes. They will last longer’ I say. It would be a great analogy if not for that most of these patients don’t have plumbing in their homes. Diabetes is a bit harder, I just tell them like I would a child, too much sugar in the blood can make you go blind, or damage your organs, make you lose your feet. I am still working on that one. I explain this all to the cowboy. ‘Sometimes we need to do more and more to make the sugar levels stay down, and if we run out of options we go onto the insulin.’ I say. I think he understands. He answers with a nod and asks me about my accent. When I tell him I am from Argentina his face lights up.
‘You have the real gauchos there!’ He says with a glimmer in his eye. ‘You know I trained in equestrian psychology under an Argentinian. Martin Arduy was his name. I break in horses. They bring me the toughest horses in all of Panama to break them here on one of my farms.’
‘Amazing!’ I reply ‘My father is from the North of Argentina, in the mountains. We had many gauchos on our farms once. The way you break horses is incredible’
‘I am no gaucho, my friend. But I learned from one. He is great man. If you ever meet him you tell him you met me’.
He is on just about everything for his diabetes except the kitchen sink and the injections. I make sure to take a good look at his feet, and after removing his big boots and stockings he tells me about the chronic pain he’s had in his feet for the last nine months. ‘A burning pain’ he tells me ‘it comes on worst at night, sometimes it feels like stinging’. My heart begins to sink. The beginnings of diabetic neuropathy indicate that the damage done to the small arteries and nerves in his limbs is now past a point of no return. It’s not really a matter of ‘will it happen’ anymore, it’s a matter of ‘how fast’. To boot, he’s been waiting for me to see him for so long that he’s now missed an afternoon dose of his medication, which means that his elevated glucose reading I get with the glucometer could be due to that alone and I can’t make any changes to his drugs with confidence. He is hardworking man, and has muscle pains from horse-riding, he tells me about how he sometimes has to ride for days at a time between his many farms. Some patients you just can’t help but be amazed by. I wanted him to invite me to his house, to show me his farm, and get to know everything about him. I felt sorry to know the extent of his disease. It always hurts a little extra. I gave him some paracetamol for the pain and told him to take his tablets ahead of our next visit in a month. When we wrapped up, he insisted on not taking up any more of my time. He reached out to shake my hand and I could have declined, covid and all, but I shook it anyway and he nearly broke my wrist. I wonder how he’s doing now.
Other patients fascinate you for different reasons. We had one man, who seemed to come out of nowhere. We had no documentation on him whatsoever, despite him living in a house right next to the rancho. He came in with a niece that said he suffered from cognitive impairment all his life, something like a disability. Sam had run his intake, and told me she wanted to sit in on his consult, as to her heappeared quite strange. I would quickly understand why.
He was amazingly friendly. Trying to coax any sort of history out of him was nearly impossible, as he constantly took my train off the rails asking me if I liked cats or telling me that he has many animals that he loves with all his heart. He had flamboyant mannerism that resembled a 1980s George Michael, if you catch my drift. At one moment he reached into his pocket and pulled out a piece of paper, it was an STI panel, and all the boxes empty except for one that had text written in it, next to a box marked HIV.
