The Doctor to be joining us, like many of the volunteers and lead medics that came to Floating Doctors, was Dutch. This was a result of a travel show, one of the most popular in the Netherlands, featuring Floating Doctors as part of its series of interesting places in the world. The better part of the expatriate staff and volunteers here during normal operations were Dutch or American. There was a little bit of others mixed in as well.

Thursday clinic was starting to find a familiar feel for me. This week we were reviewing a patient that Alison had seen three weeks prior (when I was stuck in La Sabana for an extra night after the horse-related trauma incident). This thirtysomething year old gentleman was in rough shape when he was seen last, having suffered a relatively quick deterioration over the last year. He began having intense seizure episodes lasting up to fifteen minutes, about once a week. His demeanor has also changed completely during that time, as he struggled to maintain eye contact and couldn’t follow the most rudimentary commands. The family also noted that he’d gotten lost at one point for three days before being found wandering one of the trails. They have no idea what happened to him during that time and he has no recollection of the events. Even if he did, he likely wouldn’t have the functionality to articulate any details. Alison and Ben in conjunction had agreed on a plan for him and commenced a treatment with anti-epileptic medications. It’s unusual for a grown man or woman to suddenly begin having crippling seizures without an organic cause, so it becomes important with any person who has a first time seizure to cover the basic examinations. Imaging of the head for a cerebral mass, electrolyte and toxin levels in the blood stream, as well as assessment for any sort of previous trauma that might have triggered things. In this population in particular you have a higher index of suspicion for one thing that we don’t really see in the West anymore: worms.

Helminths, or parasitic worms as we call them, are exactly that. They are different species of worms and there are dozens and dozens of them. They don’t occur in the developed world, in part due to colder weather and more hygienic practices, but they been our biological adversaries for millions of years since the beginning of mammalian existence. For example, the hookworm Necator Americanus (ingested via contaminated food), lodges into the small intestine where it leeches your blood over many months, producing an iron deficiency anemia. The pinworm Enterobius Vermicularis also colonizes the intestine, and after dark crawls towards the anus to lay its eggs, which causes intense itching of the anus at night. Ascaris Lumbracoides, the giant roundworm, initially doesn’t cause much harm at all, just hanging out inside the gut and consuming food. The problem with Ascaris though is that they multiply, and can grow up to 35 centimetres in length, which in small children can be enough to cause malnutrition and completely obstruct their bowels requiring surgical extraction. Filarial species of worms can accumulate in the lymphatic system of the limbs and cause obstruction resulting in elephantitis of the lower legs. They can also invade the eyes and cause river blindness, which is the second most common cause of infection related blindness in the world. Echinococcus granulosus, whose intermediate host is dogs, can invade the liver and the lungs to cause hytadid cysts, which are parasite containing bubbles that can rupture, causing a sometimes lethal anaphylactic shock. Tanea Solium, the classic tapeworm, presents differently depending on whether you ingest the larval form or the adult form, one causing worms in your gut that eat your food or larval deposits into your brain and organs that form cavitations and turns you into swiss-cheese. The list goes on and on.

As a matter of fact, worms have been common foe for so long that we have an entire division of our immune system (the IgE branch of immunoglobulins) evolutionarily programmed to fight them. In the absence of our tubular nemeses, this anti-worm immune system of ours gets confused trying to find enemies when it has none; picking fights with completely innocuous stimuli because they need somebody to fight against, which manifests as allergies. This is exactly why allergy rates are almost non-existent in populations with a high incidence of worms, and it is why we generally encourage people to not use alcohol based disinfectants on surfaces that their babies play on, as that prevents their immune system from developing a healthy amount of practice fighting against real vermin instead of normal stimuli.

For this patient, his sudden change in neural function could be a result of Cysticercosis, the deposition of the Tanea tapeworm in the brain, which can be nasty. He would need Xray of the brain and muscles to check for that. On this visit, his second, he was much improved on an increasing dose of anti-epileptic medication. I met him for the first time and he seemed like an impaired but reasonable human being, a statement which made Alison’s jaw drop with amazement at how much he had improved from the last visit. He was still struggling to follow some multi-step commands, but was able to lift his arms and mirror me when doing a neuro-muscular exam. This was a tremendous victory, but it also highlighted a sobering reality for neuropsychiatric patients in low-resource settings like this one for other reasons.

His family was eager to continue pumping up the anti-epileptic durgs as they desperately needed a return to functionality so as not to burden his kin. In a place where things were tough enough, having a grown adult that ate and took up time to maintain was a serious handicap for all. I was aware of this from previous reading. Some of the places where one would think psychiatric services are not a priority, are where some of the most dire and tragic patients need them. Mentally ill patients in crisis zones are often neglected by their families or cast out by their villages due to fears of demonic possession, sometimes left to wander into the savannah to let nature have its way. I’ve had psychiatrists who missioned in Africa tell me they simply don’t know what to do with psychotic patients in some places, those with catatonia and strange manifestations get locked away in cages if needed. If you can’t carry your weight out there its unlikely somebody else will. I wondered to myself what kind of destiny might befall our patient here if his symptoms didn’t respond to our medications. A state run psychiatric inpatient facility? Wishful thinking. Maybe in Panama city for those with insurance.

During lunch I got to meet my new boss, who would begin her isolation on base for two weeks starting at the moment of her arrival. I was sitting eating lunch in the dining area when Jack came in leading her on a socially distanced tour of the base. I introduced myself.

                ‘First time here in Floating Doctors?’ I asked

                ‘First time in Panama’ she answered.

                ‘Ha! You’re just like me but four weeks ago. Look at me now, sitting here, it seems like I know exactly what I’m doing’ I said with a grin ‘That will be you in no time. Don’t sweat.’

It is interesting to think about how far I had come in only one month on the ground. After the first week I stopped correcting people when they called me doctor, as it just caused too much confusion. People came to me left right and centre around the base for sore throats, queries about their kids, asking me for pain relief or advice on sore teeth. I prescribed antibiotics when I felt it necessary without thinking twice, I had the cojones to get creative with treatments and go off the script because we had no script time and time again. I had become the guy. I still remember my first clinic how my fingers trembled while I dialed Dr LaBrot to ask him what to do about a lady with a blood pressure of 170/100, to running a trauma in the jungle alone just a few hours later. This trial by fire and freedom to think and act had made me into hardened steel, although certainly dull and out of shape. It’s like my father says: ‘The dog doesn’t learn to swim by sitting on the edge of the lake’. By golly I was swimming

When I sat down with Dr Nicole later that day and took her through a handful of charts just to give her a flavour of what we were doing, she seemed more taken aback than I was when I got here. She has a career interest in obstetrics and gynecology, and so I told her about my two cases of Pelvic Inflammatory Disease and nearly a hundred pregnant patients.

‘So you just treated with antibiotics? Have we got the capacity to test for inflammatory markers? Sample analysis for the bacteria to find out what it is?’ She asked.

‘The only blood we take is for hemoglobin and for glucose. The hemoglobin is actually new, we didn’t have it before’ I said.

‘Okay…’ She answered. ‘And for the pregnant patients. We have no ultrasound you said, what can we even do?’

‘All the rest I guess, fundal height, doppler, counseling for nutrition and urine dipstick for protein in the urine. Keep in mind most of these women have eight children and hardly see a doctor for any of them’ I replied.

‘Right, of course’ she said. She was coming off a year long stint at a brand new well-funded hospital in one of the Dutch Caribbean colonies.

                ‘You’ll notice from what I’ve been telling you…’ I said, almost defensively ‘We do what we can’

A certain part of me was sad that I was no longer going to be the highest rank, but I knew this was the best thing for the patients and for my own growth as a clinician. Having a doctor with two years of experience already, one in Europe and one in the Caribbean would provide me an amazing resource to learn, and a more direct mentor. I am just glad that she arrived before I flew too close to the sun. If only Icarus had himself a Dutch superior before he tried to flee his prison. Perhaps he would have made himself some clogs instead of wings and walked on water instead.

The rest of afternoon clinic contained a few more cases. A woman with a history of what she described as vaginal discharge associated with a cramping pain that tracked up her leg into her back. Her speculum exam showed an odd white discharge, very watery, although very little, with a perfectly healthy looking cervix and no findings on her urine dipstick. We put it down to vaginal candida and gave her some cream because it was the only thing that made sense despite not feeling that comfortable with our solution. We also had a returning patient from the previous week with asthma type symptoms that didn’t seem to respond well to the first line inhaler for asthma, but showed some response to the steroid inhaler we commonly give as second line. After a back and forth discussion between myself and Alison we decided to try him on a short course of steroids as a diagnostic treatment more than anything. If it worked we knew it was asthma with a weird response to inhalers, and if it didn’t we knew that we had no idea.

This gentleman also turned out to be a barber, and as per my request came by to the base the next day to give me a nice cut. He came by in the afternoon and asked if we could do it on the porch of the casita, facing the water, which seemed a mighty fine spot to me. As I lead him to the porch and brought out and extension cable, he opened up a black case, one of those plastic ones for electric screwdrivers. Inside it dwelled an old clunky plug-in razor, with different sized guards for all the lengths. A few different pairs of scissors and straight blade razors were complimented by a handful of little vials filled with different coloured liquids, and a toothbrush and a comb rounded out the equipment. We set up a plastic chair facing the ocean and I set up my Bluetooth speaker, he told me he like Damien Marley, so I gave him what he needed. When he asked me what I wanted hair wise I told him to go crazy. ‘Dame la Panameña’ I said. He laughed and nodded.

Draping me with a thin plastic sheet, he got to it, first assessing his plan of attack. We made small talk at first, mainly about his asthma, and plans for the weekend. He was twenty four with three children, and liked to play baseball. I felt him slowly leave me, becoming entranced in the task in front of him with nimble fingers. He diligently faded the top with sharp precise lines. At one point I saw him dig into his case and bring out what looked like sachets of sugar. He pulled out two razorblades and danced around the edges of my beard like a droplet of water in hot pan. In the moments that his eyes were in line with mine, I saw his eyebrows furrow with laser focus. It was like our roles were reversed. I was now the patient, and he was the man in charge. This was his ritual. I treated his ritual with respect, sitting quietly against the rasta vibrations of Damien and Ziggy. Ethereal greens of tree and blues of sky bounced cleanly off the tranquil water in front of us, and I spoke only when spoken to. He took his time, all the amount needed to do it right. I imagined if that might change if he had 48 cuts to do in one and a half days.

Barbers and Doctors share more similarities that you might think. As a matter of fact, barbers are the original surgeons. In medieval Europe, barbers were the ones who did surgery as it was considered ‘beneath’ the common physician. For centuries it was barbers who pulled teeth, performed bloodletting, did amputations, and applied bandages to the wounded. The classic red and white striped barber pole that we still see everywhere today, was that colour to represent the blood and bandages applied by the same men who cut hair. In the UK and Ireland still today, surgeons go by the title of mister instead of doctor, which dates back to the initial segregation of doctors and barber surgeons in the UK, who were trained through an apprenticeship instead of through medical school.

When things wrapped up I paid him and said thank you. ‘You can leave this mess for me’ I said, looking at all the black fluff that littered the porch. After he took off I had a look in the mirror, he really gave me the full Panameña. I looked more like Pitbull than I ever knew I wanted to. I was reborn like a Phoenix, turning the page on month down and one to go here treating patients.

Mr Worldwide was here to stay