We were up at our usual time and finished breakfast to begin clinic at 730. By 8am there was a line swollen enough to fill the whole day already. I addition, we had one house call to make, a chronic patient who wasn’t mobile. As I gathered my things for the visit Jack explained to me her situation. She lived a forty five minute walk away. ‘Hold on, what? Forty five in total or forty five both ways?’ I asked, and I didn’t like the answer I got. Getting to her would mean forty five minutes there, forty five back, and a consult of who knows how long. We would be using up two hours of time to see one patient. ‘What do you want to do?’ Jack asked me. I stood there dumb, eyes still drowsy from the morning, coffee not having yet kicked in after a poor night’s sleep—I was surely developing some viral pharyngitis, having woken up during the night with my throat swollen and a grape sized lymph node at the side of my neck, which made the rest of the night in the hammock harder than usual—I looked at the line. I weighed the pros and cons. I thought about this poor woman, who lived so far away. The decision gnawed at me, do we go and lose close to half of our clinic time here for the day, or do we stay? Is there a right decision here? She was one of our chronic patients, and in theory that’s what we were here to see and nothing else, and just because I wanted to see everyone I could didn’t mean that the chronic patients should suffer as a result. On the flip side though, for all we know she just needs her meds, and that’s that. If she ran out of drugs any values from her glucose and BP would be useless to us anyways. Jack stood there waiting for an answer, while rusty cogs churned in my brain.
I told Jack ‘Listen. The trade-off just isn’t there. I can treat five, six, maybe as many as ten people if I am lucky in that time we would lose just traveling from point A to B. Send a message that we’re sorry. Send her medications. We’ll see her in three months I promise.’
‘Okay’ he said.
Again I started the day with a black cloud hanging over my head.
Many patients that came in early were young mothers with young children, as was so often the case. After three weeks in the field now I was starting to get a handle on the most common presentations in this population. So many things that in those first two days in Pueblo Nuevo and La Sabana I had not much understanding of were now elucidated by their commonality. That’s hypomelanosis in drops, it’s very common, don’t worry about it. Those are excoriated bug bites, just use coconut oil and trim the nails as short as you can. That white stuff on his neck is what we call Vernix Caseosa, produced by the baby’s cells to prevent infection and protect the skin, it should clear up and it’s not a bother. How many times per day is the baby urinating? Feeding? It was a weird feeling to know more than a mother, in particular because on that morning I saw three or four first time mothers that came in alone, without the help of Gran. I saw a 3 day old, a 6 day old, and a 7 day old. I wonder what big celebration coincided with all these pregnancies, doing the math I realised it was just around the time of the first covid lockdown.
‘Ah’ I thought to myself, ‘the boom is real’.
Our portable hemoglobin device had become my new best friend. It was so much easier to feel reassured when patients came in presenting with general tiredness, like so many of the elderly do. It is isn’t an easy diagnosis to tell someone that they are old, and that’s why their hands and knees hurt, why they can’t sleep as well as they used to, or why they just don’t feel as good as they once did. Often I’d see older men and women with bilateral hand pain. ‘It hurts when I use them a lot, and also my knees, also my back.’ An examination of the hands for signs of Rheumatism has not yet once shown me the classic ulnar deviations or swan-neck deformities that I remember from my youth in Argentina. It’s tough for us to appreciate how common and how tough Rheumatoid Arthritis is. Our medications are so good now that we just don’t see those crepuscular hands that used to be so common. I bet if you asked my parents’ generation they’d have dozens of family friends or distant relatives with the classic RA hands. I was on high alert here and yet every time it was osteoarthritis, wear and tear. I’d always try to make it a point of humour ‘These knees have walked enough for three lifetimes, and so they’re going to be well worn’ I’d say, or ‘When the grandkids start acting up, I prescribe a flip flop or a stick, it’s easier on the hands’. I can be a charming devil at my best.
I called a snap meeting of the team around noon, we were meant to leave within the hour, and I had just spoken to our captain in passing as he was getting some things sorted. I told Jack and Chrys the news
‘I just talked to Mancha. We’re going to try something crazy, if it’s alright with the two of you’ I said. ’The river mouth, the wind, it’s always a nightmare, you guys know. Mancha wants to try leaving the other way, up the river, all the way up a series of tributaries that lead back out to the ocean on the other end of the peninsula. We’re going to take two boats; one of them will be a guide group of locals. This will enable us to leave at four instead of one, which also means we’ll likely wind up navigating Open Ocean as night begins to fall. Have either of you got any objections to this?’ I realise now in retrospect, that the way I phrased it hardly gave them a choice. They both nodded and told me no problems at all. That’s the spirit, I thought. Meeting adjourned. Now where was I…
This temporal development gave me some breathing room to see patients with a bit more tranquility, knowing that we hopefully wouldn’t have to leave anybody unseen. As I continued to churn through consults, I came to one lady, a lovely woman, quiet but with a sense of humour, and very kind. Her eyes hung sleepily against features wrinkled from the sun, and she wore a headdress that gave her shaman’s zeal. She carried a stick with her, a long bamboo shaft reminiscent of Rafiki from my youth. She tells me it helps her walk. I joke with her that it keeps the family in order as well, and she smiles. I began taking the history like I usually do and her symptoms seems fairly consistent with aging. Tired during the day, often feeling like she needs a nap, something I told her she should go ahead and do if she feels like it. She also gets tired very easily when she walked, feeling short of breath sometimes with a little pain, especially in the heat. Sometimes she felt light headed in the hot sun, although she didn’t drink much water. ‘My hands are sore, my knees are sore. I’m tired.’ She’d say. ‘Okay, let me see what I can do’. I prick her for blood and check her hemoglobin, which comes back normal. Fair enough, she’s not anemic, just old. I tell her what I think, that I can probably give her some things for the pain and she should drink more water, unfortunately these symptoms come with age. Then I move on to my ritual, starting with her pulse. It’s strong, with a normal rate and normal rhythm. I move my stethoscope over to her chest, and I listen closely. I can feel a sense of Zen from her as she closes her eyes, trying not to interfere with my calm but deliberate silence. I hear her heart pulsing, and then a whoosh. It catches me by surprise.
I placed my stethoscope more diligently, second time, purposefully along the second intercostal space the right of the sternum, its subtle but it’s there, a murmur in the aortic region. I could hear it across all four valves. I ask her a few targeted questions, remembered ASD, the triad of aortic stenosis drilled into my head as a second year medical student by a zany cardiologist.
‘This shortness of breath and slight chest pain, it comes on when you’re walking, any other time?’ I ask
‘When I am moving around’ she says, ‘Cooking, or carrying things as well.’ She has angina and dyspnea on exertion, A and D.
‘You told me at times you feel light headed, that’s when you’re walking as well right, ever fainted?’ I press her further
‘Oh yes’ she says, ‘a few times actually.’ Syncope, that’s S, completing the triad.
I realise now that she’s got symptomatic valvular disease, so subtly hidden by her age and stoic demeanor, that I nearly missed it completely. I would have never guessed it were it not for my stethoscope. I scribble this all down on my chart. I’m excited, a good catch, well done doctor. In the face of a cryptic diagnosis, it was my ritual again that saved my skin. Every time I listened to a heart and heard nothing of consequence had served its purpose. I shadowed a doctor once at Connolly hospital, a senior registrar in pulmonology. He told me once that it was important to listen to as much of normal as you could. ‘You will hear normal 100,000 times and should 100,000 more’ he said, ‘Then one day you will hear something that sounds normal, but it doesn’t quite sit right. It’s different. That’s when you become good at what you’re doing.’ My excitement turns quickly into a sense of disappointment though. What I am I going to do, replace her valve? Hardly. I tell her everything, about her symptoms, about what I hear, and what I think. ‘I think it’s got to do something with your heart, but I can’t say for sure just yet.’ I encourage her to drink as much water as she can, stay out of the hot sun. When we come back in three months we will bring the right machines to do a proper cardiac appraisal, with the cameras and the cables. In the meantime you can sit tight and take some Paracetamol for your muscle pains. Stay safe and good luck.
Later in the day, as things are winding down, I got a familiar visitor. It was the woman from the night before, the one that I think has panic attacks, who I gave some paracetamol to trial for her pains and then failed to provide the stool softener that I thought she needed, much to my chagrin. She wanted me to see her daughter; she has a toothache, and has had it for the better part of a year. I already didn’t like this, I’m not even a doctor, let alone a dentist. A quick look into her mouth reveals a completely split molar on the back left side, and another molar next to it that is half black. She has a slight lymphadenopathy on the left side of her neck as well, but no fevers, and no systemic signs. Mom tells me that after eating it gets sore, and every now and then her jaw gets a bit swollen and she spikes a fever. I know the only real solution here is to take either one of both teeth out, but I wouldn’t have a clue as to what I was doing. I had lidocaine, but I don’t think we had pliers, would I even use pliers? This isn’t my uncle we’re talking about either, who would take it on the chin without a word, but a six year old girl. ‘I’m sorry’ I tell her. ‘I can’t take that tooth out, I don’t feel comfortable, and I know if I messed it up we’d be in bigger trouble.’ I agreed to give her a course of amoxicillin, hoping to clear up any lingering colonisation or infections that might make her a little bit less sore, although I knew there remained a possibility it did nothing at all. I considered antibiotic stewardship and went for it regardless, rationalising that surely it would help to some degree, at least transiently.
In retrospect I don’t know if it was the right decision, but I was starting to get used to making tough decisions out here. There is just no way around it. Despite this I will admit one thing: I surprise myself regularly with how much I know. In classic medical student fashion, there is so much that we pick up during my training that feels locked away and inaccessible until the moment calls for it; and then all of a sudden I am counseling a sixteen-year-old girl on the ins and outs of genital herpes flares, or walking a first time mother with a three day old child through the importance of a growth chart and how much to expect her baby to feed and urinate in the first few weeks of life. I have learned above so many things out here that I can trust myself and my training, even if I make the wrong decision. I have a brain and I have reasons for doing what I do. I only wish that some of my colleagues would come down here and learn this for themselves, I have seen firsthand how the intellectual and competent live crippled with doubt, and I don’t know whose fault it is. Sometimes I just wish they’d believe more in themselves. ‘You got the stuff’ I always say to my most anxious colleagues ‘Don’t doubt that for a second.’
Our clinic, for the first time ever, wrapped up half an hour before our last possible moment we could leave. A stellar achievement, which gave me some time so get my things together calmly and chat to some of the community leaders that always hung around when we were finished. Some of the older men came up to the clinic table and I showed them our gear if they were curious. One of them asked me if we had any tablets for sexual potency, and I told him I didn’t, but that maybe I could get some. He turned to his friend.
‘See, you can take a pill and fix all your problems!’ he said to his friend, and they both started laughing. They were messing.
‘No no’ the friend answered with horror in his eyes ‘Whoever invented those pills is an evil man’
‘Or maybe he’s quite the opposite’ I said. ‘A great man indeed… a friend to us all!’ We laughed for a while. Boys will always be boys I suppose.
There was a lady whom I gave a consult the day before, that was waiting to speak with me in particular. She was tiny and happy, and thanked me for coming. Then she handed me a handmade purse.
‘This is for you’ she said. It was a classic Panamanian carterita, just one pouch and a strap.
‘Oh my goodness’ I said. ‘I love it, look at me now. I can put my things in here. Thank you so much. I will treat this with respect. I mean that. I mean that really, thank you’ She blushed and told me to quit talking nonsense. I asked her if I could get a picture with her and the satchel. I want to show it to all my friends in the whole world I told her. She had no objections.
‘You can put your phone in it, see? Floating Doctors has been coming here for many years. You have done so much, I even told Ben that I would give you something. When is he coming back? We miss him. Take another picture with us here and show it to Ben, this is my son, he must have seen him when he was so little!’ She said.
‘I don’t know, hopefully soon. But you know we’ll be back in three months, someone will be here’ I answered. She walked with me down to the boats which were already loaded. A big group of people were there waiting to see us off, included several patients I had seen over the last two days, part of the almost 50 we saw in total (insane). They waved goodbye to us from the beach as we motored up the river. Our presence in their community was of that much value to them, I was humbled. To a certain degree though I understood I was just a speck in the FD machine. The hard work of so many people for over a decade produced this moment, I just got to be the one to take the glory on this day. It takes a village as they, and I want that image in my mind to stand as a testament of what can be achieved by a dedicated group of people determined to make a difference.
