First on the agenda for Monday involved chasing down all the loose ends from the previous week. I put together a bundle of medications to be posted to a gas station nearby Pueblo Nuevo for ne of our contacts to pick up and have brought up the mountain by whoever passed through heading that way. The sheer difficulty of arranging follow up and getting messages across was notable. Our societal webs back home never place us farther than a few degrees of separation, even for those without traditional cell phones; you can shun all forms of technology and still be traceable via basic post, or landline into somewhere who could find you. Somehow for the people of these communities, that middle ground of landlines and telegrams was never there, leaving an empty vacuum, and without cellphones to make up the difference just getting through to someone was like pulling teeth.

This week’s trip was taking us to the Bisira, one of the more newly scouted communities on the rotation, first contacted in 2018. I would realise this later but the relative youth of the relationship meant many patients were still stuck between the cracks, convenience never having brought them face to face with a Floating Doctors clinic on their previous visits. It was a village on the mainland again, technically anyways, although the only access was by boat up through the Rio Cricamola. It was a treacherous body to navigate, and we were going to sail out two hours from our base to the mouth of the river, and there be met by a group of locals who would take us the rest of the away. To attempt it without their guidance was essentially a fool’s errand I was told.

Travel by boat enabled us to repack an improved version of the pelican bags. After three days in the field I was able to provide much more useful input for the materials this time around. We were bringing a basic ‘follow up’ bag, with all the patient prescriptions pre-packaged in our own pharmacy. Additionally, we brought a surplus of our most commonly prescribed chronic medications, mainly metformin and amlodipine, in the circumstance that patients needed an increase in dose after assessment in clinic. This was really what the main purpose of my presence here was meant to be, just to have someone with medical experience who can appraise based on clinical findings if treatment is adequate or if something needs to change to chronic medications. For the expected that you always see in any GP setting like simple headaches or muscular pain, we were hauling massive jugs of paracetamol and ibuprofen, which commonly come back empty.  A myriad of other basics formed the bulk of our medication bag, things like saline eyedrops, antifungal creams, ant-acid tablets, coconut oil (the emollient of choice), and anti-lice shampoo. There was also the first aid bag, complete with gauze and dressings of various sizes as well as a full wound care package; this bundle included two sets of sterile gloves, 3, 4, and 5 unit sutures, as well as the basic tools like suture clamps and tweezers. A handful of antibiotics, cephalexin, amoxicillin, metronidazole, and ciprofloxacin rounded off our medications. Our diagnostic equipment was fairly rudimentary but also robust, everything for vital signs, a scale, a tape measure for height, urine dipsticks, pregnancy tests, a peak flow meter (for forced expiratory capacity of the lungs), otoscope and fundoscope, glucometer, a portable hemoglobin assay that could spit out a reading in thirty seconds, and a Doppler ultrasound. It really was a mobile general practice clinic. One small Oxford handbook or clinical medicine and the pediatric British Natural Formulary were my resources for when the unknown struck. The Floating Doctors app also had a fully immersive and easy to use guide on common presentations and management. Looking at it all at once I realised it actually was quite a lot—the only thing missing was a doctor. Putting together these supplies as well as our regular giveaways of food, soap, toothbrushes, and other goodies took most of the time.

Later in the work day, as we were putting the last pieces together Anselmo came calling for me. ‘There’s someone out at the dock’ he said.

Righto, there’s my cue.

I walked out to find a boat full of people, an older woman, a man, a woman, and four children. The woman, who sat in the middle, was in awful pain. She seemed to be in a bad way, so much so that I felt to try and bring her out of the boat would do more harm than good. I cleared everyone out onto the dock and hopped down to take her history. She had a chest pain, severe, most days. It was associated with a stomach pain, in the lower third of her abdomen. She said at times, like now, it was unbearable, but would tend to go away after a while. I began scrolling through the list of differentials. No bowel changes, no fevers, no coughs, the pain itself caused an intense nausea that made her vomit. I asked about her situation down below, and then began a different line of questioning, one specific to women. Medicine is funny like that; it makes it impossible to play the PC game of equals. What some people call clinical savvy is just another word for prejudice. If someone comes in looking disheveled, telling you they’re homeless, you treat them like an IV drug user until proven otherwise. If a woman comes in with lower quadrant abdominal pain your first and most important differential is an ectopic pregnancy by virtue of their sex and sex alone. Caribbean (i.e. Black) men and women over the age of fifty get a different first line medication for hypertension than non-blacks, deemed to be more effective. This may be inherently good or bad, I can’t say, but that’s just how it goes. She had some pain with urination, and a missed period. She also had some discharge. It was smelly she told me. In terms of sexual partners she told me only one in the last four months, a boyfriend.

I quickly realised this was going to require a more intimate examination, and despite her pain I urged her to let me help her out of the boat. She came into a spare room inside the bunkhouse with a bed. I got Kelly to act as my chaperone as I examined her. Her abdomen was exquisitely tender to touch, and alarm bells started going in my head. Speculum exam revealed a thick grey discharge coating her cervix. It smelled dank to say the least, and I called the boss to report the case and all the findings. Cervicitis definitely, pelvic inflammatory disease possibly, and thus we would treat with three antibiotics to have all the bases covered. Her lack of fever at the least was reassuring. I told her that these types of infections required treatment of both her and her partner, as they can be retransmitted back and forth unless they both get treated; I would give some for her partner but he’d have to come back to us for the injection. ‘My partner is here’ she said, the man in the boat. She also asked if she was pregnant. Good question. I got her to make some urine and dipped it with an Hcg strip before I stepped back out to prep the injections and collect the partner from the dock.

Coming back into the room, I looked down onto the pregnancy test I had left there percolating. Two stripes, that’s a bogey. The plot thickens. I called the boss again. She was now a high risk pregnancy, an infection tracking up into the womb has severe complications for her and for the baby, she would have to go to hospital and get treated there. I sat with her for a while and told her the news. She didn’t seem terribly moved. I found this to be a trend here, maybe because pregnancy is so rampant in the villages, I’ve yet to see the revelation come as a shock to anyone. I told her that it would be best for her to get IV medications at the hospital in the nearest town. But ‘I can treat your boyfriend before you go with his injection here though.’ I said

‘He’s not my boyfriend’ she said. ‘My boyfriend lives in x’

The plot thickens further.

She insisted that she didn’t want the lover to know that she was pregnant. ‘He means nothing’ she said (something along those lines). ‘He’s gone. I’m done with him.’ Okay then. ‘What we discuss stays between us’ I said to her. This was probably not the best moment to counsel her on the importance of disclosure to all her partners regarding her cervical infection, but I did it anyway. I even offered that we could do it for her if she wanted, make the call and tell whomever, and that we were happy to take on her care for the duration of her pregnancy. Alas I let her slip out to the dock, standing oddly as she left, debating to myself whether I should pretend I had just treated her or not, and then brought in the lover for his.

I let the situation sit with him and gave him the shot. I thought about how best to phrase what I said next without giving myself away. With a pretty awful poker face I said to him ‘Listen I say this to everybody, but it’s important that if you have multiple partners to inform everyone so they can get treatment. We don’t want these things spreading from person to person.’

Smooth, pseudo-doctor Juan. Real smooth. He gave me an awkward nod.

I followed him out onto the dock to give the woman a letter to bring to hospital. Her plans had changed she told, she was going to go back home and go for hospital tomorrow, despite my insistence that she go today. The cumbersomeness of the situation reached its apex when I left them all sitting on the dock together and tried to find someone on base who could help me find them some gas for them. I felt like the world’s biggest dunce leaving them all there to stew. I can’t imagine how they felt.

After they left, I returned to my daily, had a meeting to review the patients for that week’s mobile clinics, and spent the rest of the evening getting ready in attempt to prevent another equipment malfunction—I know now that this is a laughable notion. Right as I wrapped things up late in the evening and sat down to relax, I got a knock on my door. It was already dark, I grabbed a flashlight. It was Jack.

‘Someone is here to see you’ he said. The buck never stops.

A women stood at the dock in an anxious fit. She explained to me about her daughter. An appointment today, another appointment made for Friday, a delivery, ‘high risk pregnancy, what does that even mean?’ she said. I told her to calm down and we worked backwards slowly. It turns out her daughter, who was fifteen, was 9 months pregnant. A doctor told them today they would have to get induced on Sunday, but she the mother couldn’t understand why and asked for my help. I had no idea where to begin. A doctor has already seen her, I thought to myself. This person definitely knows more than I do, what am I supposed to do? I followed her to the dock in the darkness and met her daughter. She had some documents given to her in clinic that day for me to look over. I couldn’t find much in there, she was just fifteen, perhaps grounds enough to consider it high risk, but why induction? I told her she’d have to come back on Thursday, we have an ultrasound machine and maybe with Dr LaBrot’s help we could give it a go at assessing her ourselves. She thanked me endlessly, with a silent word goodbye I watched them turn into a darkened silhouette that faded off into the night.

Nice, I thought to myself. Something to do when I get back.