I woke up on the morning of our third deployment to some welcome news via email; my request to the college for a one month extension to my placement was well received. Despite it being so clearly outside the realm of normality, it is so relieving when you encounter people capable to overrule policy after intelligent contemplation. Going straight to the top was the only way, and thankfully having an accessible leadership team made this process a thousand times easier than I thought it would be. I hardly had time to bask in the moment of glory though; the boat was packing up and leaving. Having made the necessary adjustments in my gear (primarily in the footwear department), I was excited at the chance to flex my new kicks on Rio Caña. Still though, my lack of adequate rain gear was once again exposed, this time not shortly after the boat left the dock and a cluster of nefarious looking clouds menacingly crept in our direction.

Once again the boat was loaded to the brim, making sitting in any sort of position uncomfortable. Jack somehow found a way to take a nap on top of all the clunky gear whilst getting doused in rain and saltwater. The man was a machine, despite his tremendously tender demeanor and maternal instincts that at times oozed neuroticism; there was no denying he was a grinder. Beneath our boat I felt the swell evolve from short choppy waves into lengthened peaks and smooth valleys, we were now out of shallow waters and into the depths of Open Ocean. The storm clouds overhead made our journey uncomfortable, and a certain tension permeated through our many bobs and bursts that cracked against the side of our bow. Breaking out of the bays (a feat which seemed to me positively ludicrous considering the meagre size of our vessel), a crack formed in the soot-coloured clouds like a beacon on a mountainous peninsula in the distance. This was the peninsula that we would round before turning up into the river mouth of the Rio. After almost three hours ride, we closed within striking distance and stopped to have a good look at the river. I had been warned before we left that the opening funneled into a small channel, which was deceptively sharp in its rise to shallow waters. The last time the boat tried to enter this river mouth some several months before, it tipped over completely. We motored slowly at a safe distance and tried as a team to assess where the waves broke the hardest, seemingly so close yet so far from the many little houses that dotted a tropical terrain behind the beach. It was too risky, our captain said, and so we followed the coast back where we came. We found a house on the shore, and one of the locals, an older man who I would find out later was an important community leader, took my place on the boat to guide the captain while I walked up along the beach towards the village.

Arriving just after eleven at the village, which was caked in rainwater all over, we unloaded our materials one by one and hauled them up the side of a narrow concrete path that shifted into broken cement steps up the side of a hill, up to a flattening which housed a school and the community Rancho. The school was in great shape, with clean concrete pillars and a new coat of paint. I might have enjoyed getting taught there myself, a far cry from some of the other places I had seen in my short time here. Opposite the rancho, a large cell tower stood like an obelisk over the residents. It only received signal at odd times throughout the night, which made it a local gathering place for many of the youth after dark. They would linger not unlike many did where I grew up, with not much else to do but sit talking nonsense with the periodic immersion within their electronic pacifiers. I suppose the call of technology and that ever present sense that you are missing out if you aren’t online was something that had reached these shores as well, despite their distance from the meccas of consumerism. We set up clinic quickly, acknowledging that two half day clinics, all the time we would be affording to Rio Caña, was not nearly enough. I made quick work of my granola bar knowing full well my inevitable future decision to skip lunch, and got to work. Somehow we had forgotten to pack gloves, something which I was not pleased about, and so Jack had gone off to try and finesse some from the health outpost, leaving me to start in-taking patients without him.

After three clinics now in the books, we had developed a decently streamlined system for patient processing. One of the clinic managers would check patients in at the registration table, making sure to articulate that we were limited and that we were only here to see chronic patients or those with emergent needs—this latter comment often going ignored. The other staff member would serve as our ‘intake’ recording the basic vitals like height, weight, pulse rate and saturations using a small pulse oximeter, as well as blood pressure and glucose for the hypertensives and diabetics. This made it so that once the patients got around to me, I already had my set of values that I would use to guide titration of their chronic diseases. Always important however was to clarify whether the patient was still taking their meds, as so many of them presented with numbers that were jumping off the charts due to weeks since they had run out. To start the clinic I would usually run intake and consults myself, just while the other started churning through registrations and vitals. Even in situations like these with such low resources, it was important to bestow some sense of order and structure to the clinic. Even though for me this was much lower than the standard I was used to practicing in, for the patients it was quite the opposite; thus I felt it important to reward them all with a medical ritual.

I had a clinical supervisor once, one of the sharpest physicians I have ever seen, call me out for sitting on the edge of the table during a consult, or having one hand in my white coat pocket as I shadowed during rounds. ‘It’s important for patients to know that we take their healthcare seriously’ he said. Something about that stuck with me. I don’t like to be seen eating, sitting idly, or even drinking coffee for that matter. If I use my phone for something I always explain that it’s to look up something in one of our clinical spreadsheets, or reach out the boss. Optics is very important in the ritual. Even if a patient has nothing to say, the type that sits down in front of you and says I am fine just give me my medication, I insistent on taking their pulse by hand. I feel gingerly, as long as it takes to find the radial, watching the second hand on my watch move step by step as I sing their pulse under my breath. Keeping my hand on their wrist I move up to their chest, auscultating the four valves. I ask them to sit forward listen to their lungs. There is no discussion here, only orders and silence. I want them to know that I am searching, that I am always vigilant. They need to feel that they are cared for. Gone are the days of telling things to a patient, I don’t tell my patients anything, I talk with them about things. I want them to understand. So often I have to be honest, and tell that I don’t know why they have this pain, or this symptom, but that I am trying. A lot of this comes from my background in psychology; I remember being taught once that the best predictor of treatment success in psychotherapy was never the therapy itself, but the therapist. If you pin the Freudians, the Humanists, Behaviourists, Cognitivists, and Mindfulness gurus against each other, the theory behind their methods is negligible against the strength of their therapeutic relationship. That is to say that you can pick any style from the bunch and it hardly matters, what matters most is that the patient, or the client as the humanists would say, feels like they are with someone who is really on their team. If there is anything I can do out here with such limitations of my practice it’s that, make them understand that I am on their team.

This all came in handy because the first patient I saw was immediately outside of my scope, which is never a good way to start. She had a mass on the base of her neck the size of a small apple. It caused her pain. A targeted history painted a picture that wasn’t terribly clarifying, she had the mass for the better part of two years, having appeared fully formed one random morning and then grown slowly over time. More recently it was making her right arm sore to use, and a brief examination revealed some impairment in her neurological function on one side with decreased sensation and a slight deficit in power. Cancers tend to grow over time and invade nearby structures in this fashion, making it my first initial consideration. The mass felt cystic however, with a certain degree of rebound. When considering a cancer diagnosis one has to consider that cancers, neoplasms, are collections of cells hell bent on multiplying at all costs due to an error in their genetic code (the famous ‘cancer genes’ we so often hear about). This is why we concern ourselves so much with what we call the ‘B’ symptoms generic to all cancers; as these clusters of cells grow, their energetic hunger becomes insatiable to the degree that they steal that energy from their host, which is why so many patients with cancer lose weight. An evolved mechanism designed to starve those cancer cells of energy kicks in to gear simultaneously, inducing a loss of appetite; in particular a loss of appetite for energy dense carbohydrates, which in conjunction with the high energy consumption of the tumours leads to the ‘cachexic’ or wasted away appearance of many people in the late stages of malignancy. This woman was exhibiting none of these signs, no change in appetite, no fevers, and her hemoglobin was right on point (we had finally repaired the portable hemoglobin machine that we were missing on our first two deployments). I was confident that it was a fluid filled mass, which although relieving placed me in a bit of a dilemma. I knew that in these circumstances, draining it would provide immediate relief for her. It would also reduce the ever present risk of this mass continuing to grow, and further compressing the neural structures branching from her neck, which if compressed for too long could lead to permanent long term impairment. On the other hand, I had never drained a cystic mass before, I had no idea what I was doing, and without the presence of a portable ultrasound at the very least I couldn’t even be certain that a fluid filled cavity was what I was looking at. I mulled the pros and cons of both courses of action, with the unfortunate absence of my supervisor due to blackout on the cell tower. What to do? Do I try my best at giving her relief and preventing deterioration at the risk of going in blind and causing more harm than good? There was always the next clinic in three month too, but might be too long, and draining at that stage could leave her with a permanent neurological deficit. I mulled and mulled. Not a great place to be.

I explained to her the situation, what I thought it was and what I thought it wasn’t. I simply didn’t feel comfortable draining it. No ultrasound, no real experience, my first responsibility is do no harm. I told her that I was sorry, we were under-resourced, I am a young doctor and I just wasn’t comfortable. I would give her some tablets for the pain and in three months we’d come back with the right things to do the job. She didn’t seem terribly happy but she understood. I told her I would try to call the boss overnight if the cell tower came back online. I had no more time to spend with her because the patients were already piling up, and with a sour taste on my tongue onto the next one I moved.

The sheer volume of Rio Caña was impressive. People came from all communities up river down here for their care, and they were a fairly committed bunch. I saw one girl, 25 years old, and certainly suffering from some sort of genetic disorder. She was probably no taller than 155cm and had cognitive impairment. She also had the strangest rash I have ever seen—I recognize that I am saying this over and over in this blog, probably because when I think I have seen the weirdest I uncover something weirder still, which I guess is the beauty of the job. Dr LaBrot told me himself that still to this day, after more than a decade in these islands, he still encounters things he has never seen before and will never see again at least once a week. Gotta love it—It was a scaling hyperkeratotic hardening, almost like snakeskin, spread across her torso, proximal arms and her shoulders. She had seen a specialist about it once, finally after many years, and was prescribed some kind of triple cream, which the mother said had helped but now they were out. She expected me to know what it was, perhaps not understanding the novelty and uniqueness of her daughter’s condition. We didn’t have so much as steroid cream packed for this clinic, at the most we had an antifungal, which I knew was no good. I didn’t feel right giving them something that I knew for certain would do nothing at all. Again I was backed into a corner, and once again I had to tell them this was outside of my ability. ‘Your daughter’s rash is really strange. I am so sorry. I don’t know what cream she was given, and even if I did, we definitely don’t have it. I can check what we have at the base, I can send you something, but I don’t know if it will even help.’ It’s funny how people come to the doctor expecting answers. It always comes as a shock to be told that I really honestly don’t know. When I find myself in this situation I find that honesty and education is the best that I can salvage. I tell them what things I am considering, ‘If it was fungal than it should itch, it should have circles with central clearing, if it was bugs I’d expect excoriations, if it was a toxic plant I might expect bullae, and I don’t see any of those things. Do you understand? I know you want answers but I’m afraid I don’t have them. Here is what I can do though…’ and I return to my ritual. I take the pulse by hand. Everyone goes quiet. I let the silence linger. The mother who hasn’t stopped talking once in the last fifteen minutes finally goes silent. The doctor is at work. I auscultate the chest, I take my time with every valve. I listen to the lungs. I look at the hangs. I am still here, vigilant. I am always searching, please understand that. ‘Leave this with me’ I say. Thank you doctor. On to the next again.

Another woman, not too long after, came to me with a mass the size of a grape on the underside of her foot. She’s had it also for a year. It hurt a lot, but only sometimes. It hurts like hell for two days at a time, and then the pain goes away for maybe a few weeks. ‘When the pain comes on I can’t even walk.’ She says ‘What is it doctor?’ Any trauma to the foot? I ask thinking maybe it’s some kind of keloid deposition. No. Does it hurt when I stretch your foot like this? As if it it’s some kind of plantar fasciitis or plantar fibroma. No. Does it hurt when I press here? As if it might be a retained foreign object. No. None of her history makes any sense. It’s totally fine at times, and other times it isn’t. Neurological exam reveals some loss of sensation on the dorsal aspect of the foot, and of the shin, even though this ball is on the bottom of her foot. Her right knee is always swollen she tells me. When the pain comes on it radiates up through her knee all the way into her hip. On examination her knee is a bit swollen, but she’s had this for a year, maybe some kind of tracking infection up the muscle strands or lymphatics? I have no idea. Even if I did, I sure as hell don’t know if I’d be able to do anything about it. I offer pain relief in tablet form for when the pain gets bad. Again I say I’m sorry, I wish I had answers. I tell her in three months’ time we’ll be better equipped to give it another look. Again I turn to the ritual. We sit in silence. I feel her wrist. With the stethoscope in my ears the outside world becomes a muzzled dog. I listen for something, but like so often in this interchange I hear nothing other than the norm. Heart sounds present, no murmurs, no added sounds. Lungs are clear, no wheeze. For these fleeting moments she has all of my attention and I have all of hers, at times it’s almost spiritual. I am trying my best for you is what I’m saying. Please know that at least. The line keeps getting longer and so I let her go.

I finally made time to eat, somewhere around five, knowing that we are going to be in it for a while still. I always feel guilty taking my time to eat my meal in silence while people are still waiting to be seen. They haven’t seen a doctor in any form since March, and here I am taking a moment to sip my water at my leisure. I know it’s very silly. Of course I need time to eat, and I deserve to take my time, but still. Nobody likes to keep somebody waiting. Washing my hands I get myself fired up. ‘This is what we’re here for Pezzy, let’s get out there. Let’s get a few done quick, the ones that don’t need extra time.’ When I say that I don’t mean cutting corners, I’m saying trim the fat.

Trimming the fat is something I hate to do. I think when people start doing medicine we tell ourselves that isn’t going to be us. I’m going to give patients all the time they need we say. We mean it, of course we do, but quickly enough in our careers we realise that how on earth are we going to see everyone. It just doesn’t work. I hate trimming the fat. The fat is what gives the food is flavour. I guess in the eyes of utilitarianism itis okay, especially in this setting, the greatest amount of good for the greatest amount of people, but I feel in my heart that just like cooking, good medicine takes its time. It is not rushed. It keeps the fat. It is relaxed, as if there is nothing else to do.

Into the evening clinic goes on. Some consults quicker than others, some I can provide very clear answers to, and some that come asking for something they already know they want, a refill on paracetamol for occasional headaches, vaginal antifungal cream, tablets for the worms. Clinic spills over into the evening and it gets dark. We had one patient who came early in the day, and had waited patiently. She had asked for a private consult, very personal, so we put her at the end of the list. The poor girl had been waiting all day, and now she sat in darkness at 8 o’clock at night. I finally collect her, and as we are walking in the gloom of my headlamp over to a private room in the nearby schoolhouse, I find out that she’s 16, and wants to talk about her genital herpes.