by long-time volunteer Dr. Anna Bazinet
At 9 years old, Mariana was confident, outgoing and so excited to see all the equipment we were unpacking that morning for the day’s medical clinic. She eagerly watched us set up the small pharmacy with medications, a scale, and a few blood pressure cuffs. She was wearing a bright green nagua, a traditional dress of the Ngäbe-Bugle people, but this was not the most striking thing about her. On her left cheek, she had a 3×3 centimeter ulcer that fortunately she seemed relatively unfazed by. As we continued to set up for clinic, I leaned over to Dr. Ben LaBrot to ask him about this lesion. Without skipping a beat he said, “leshmaniasis, a skin parasite that is carried by the sandflies.” I have since learned more about leshmaniasis and other fascinating parasites, but see this moment as the beginning of my interest in tropical medicine.
We later saw Mariana and her entire family in clinic and after learning more about her and performing an exam, we helped with the things we could but ultimately had to make the recommendation that her parents take her to the district hospital for treatment. The medication used to treat these lesions, a long course of pentavalent antimony, was beyond the scope of a one-day clinic. The family thanked us, and Mariana gave me a hug at the end of the day. I think she enjoyed watching us work and seeing patients.
This encounter happened during one of my first clinic days 7 years ago when I was first a Floating Doctor volunteer. From then on, I was hooked. I loved learning whatever I could about tropical medicine. Who would have guessed at my fascination with intestinal parasites and leshmaniasis? But, beyond the medicine, I loved the communities we were serving. I loved learning about the culture and language all while traveling by boat and regularly seeing porpoises on our commute to work. During this first trip, I had the opportunity to be in Panama for about 7 months before needing to return to Seattle to start medical school. I remember feeling very torn, both excited for the next step in my training, but sad to have to leave a part of the world I had grown to love and a set of incredible people.
Looking back, my current career path was heavily influence by this time in Panama. The mentorship and leadership that I received by Dr. Ben LaBrot and some of the other providers is one of the reasons I am currently training in family medicine. I love family medicine as it allows me to develop long-lasting patient relationships, connect with the broader community, and tackle some of the challenging issues facing patients today including healthcare disparities. This work is not unlike that of the Floating Doctors.
This September, after 7 years, I finally had the opportunity to make it back to Panama. I honestly didn’t know what to expect, I had heard rumors of new volunteer bunkhouse and base, 20 staff members, and a formal pharmacy, all of which were just dreams 7 years ago. And indeed, I was astounded by the amount of progress Floating Doctors made!
I will admit I was a bit nervous getting into the boat on the morning of the first clinic. Would I know enough? Would I live up to the providers that encouraged me along the path I am on? My nerves quickly faded as I picked up the first set of patient charts and sat down with a mother and her 4 children. My Spanish slowly came back and I started taking a history like I have done hundreds of times in many different situations. Despite the surroundings, seeing patients in Panama feels similar to the US. The chief complaints are for the most part similar; headache, rash, knee pain, back pain and insomnia. One thing I must admit is that for abdominal pain, I was not as accustomed to asking patients if they have seen worms in their stool!
Although so much has progressed with the Floating Doctors since I had been away, I was also amazed at how similar it felt. Even though they have been able to see more patients, do more clinics and keep better records, the sense of mission and commitment to the Ngäbe communities was completely intact. The feel of the clinics, the patients, and the empathetic care they receive was all just as I remember it. And finally, the organization still depends on everyone bringing new ideas, energy to problem solving and the occasional stroke of brilliance to push things forward.
There’s a lot of need for good problem solving when it comes to community healthcare in Panama. Even with all of the progress, I worry about the Ngäbe communities and the individuals I met. I worry about their increasing access to processed foods, snacks, sodas which is leading to increasing obesity rates, hypertension, and diabetes. These can be challenging issues to treat in remote communities where medication adherence and the need for at least occasional monitoring is important. This is coupled with a national health care system that makes it challenging for Ngäbe patients to get the care they need when they go to the larger hospitals.
During this most recent trip, I couldn’t help but think back to Mariana and wonder how she was doing. I could imagine her as a great doctor herself someday, with her inquisitive mind and openness with me 7 years ago. Unfortunately, I know that is a long shot for her as she is likely still living in a community where ~60 percent of people over 10 are illiterate and ~91 percent of people make less than $2 a day. For me, this is the challenge of working in Global Health and what keeps me engaged and passionate. The inequalities seem vast and sometimes insurmountable. I am constantly reminded of the work that needs to be done. I am so thankful for organizations like Floating Doctors who are able to slowly work towards change. After my time in Panama, there are a lot of projects I would love to work on, but alas, this only ensures that I will be back, hopefully sooner than 7 years…and when I come back, I can’t wait to see what Floating Doctor’s dreams have become reality.
by Veterinary Lead Dr. Thomas Easley
Veterinary Public Health (VPH) is an essential component of public health and incorporates various types of cooperation between the many relevant disciplines involved in the interaction between people, animals and the environment they share. VPH programs should not be viewed as operating in isolation, but as making an important contribution, as part of an inter-sectoral collaborative approach, to the improvement of a country’s infrastructure, economy and rural development.
Since the profitability and therefore the supply of private veterinary services is governed by several factors arising from economies of scale, such as the size of the livestock enterprises in the locality, the nature of potential or actual diseases, and the types of animals raised in the production systems, in areas where private veterinary work is unprofitable or where other types of market failure occur, economic or social concern usually makes some type of public intervention necessary. Providing this intervention to the marginalized indigenous communities of the Bocas del Toro archipelago is where Floating Doctors shines like a beacon in the night.
Floating Doctors has integrated a VPH program into their daily operation for two important reasons. The first being focused on human health in that domestic animals (including cattle, goats, sheep, pigs, poultry, and dogs) of poor people can be important reservoirs of zoonotic diseases that impact on their health, either through direct or vector-borne transmission routes. In addition, history has shown us that zoonoses falls disproportionately on poor people with poverty, and unsanitary living conditions associated with poverty, being considered potential risk factors for zoonotic and food- and water-borne diseases in many areas of the developing world. The low standards of education and veterinary public health services commonly associated with poverty and marginalized communities increases the risk of transmission of zoonoses and food-borne diseases.
More importantly, and the second reason, Floating Doctors understands One Health and perseveres to integrate its implementation into all of their activities. While One Health initiatives have traditionally focused on threats to human and animal health, such as zoonoses and a secure food supply, they have not typically promoted an understanding of the many beneficial physical and psychosocial impacts of human-animal relationships and how these can be leveraged to improve both human and animal health around the world. Additionally, current One Health initiatives are undertaken at international, federal, and provincial levels yet often fail to have an impact at a community and primary care level, especially in poor/marginalized areas.
The Centers for Disease Control and Prevention’s definition of health is “a state of complete physical, mental, and social wellbeing.” This definition has included not only physiological, but also emotional and social (behavioral and natural) states as are often described in the definition of good welfare. It is well-recognized that where there are poor states of human welfare there commonly exist poor states of animal welfare. Similarly, animals often act as indicators of human health and welfare, as can be seen in the link between animal abuse and family violence. Considering health and welfare together — because of the interconnections of human-animal-environmental factors — helps to describe context, deepen our understanding of factors involved, and creates a holistic and solutions-oriented approach to health and welfare issues.
The North American Veterinary Medical Education Consortium (NAVMEC) has identified knowledge of One Health concepts and principles as a core competency for veterinarians who will graduate in the 21st century. Despite widespread exposure and support of One Health concepts, a recent survey of veterinary students at Colorado State University demonstrated that few opportunities exist within veterinary curricula for students to get involved and gain practical experience in this area. To fully realize One Health concepts and principles and ensure their promotion by future health professionals, veterinary students require tangible, specific applications.
Important goals in teaching are to challenge veterinary student perceptions and facilitate opportunities for not only applying and practicing core learning, but also learning how veterinarians are connected with their communities and with society as a whole. By understanding these concepts, opportunities are provided for long-term personal growth. For many veterinary students, identifying their role in the community as an individual and a professional can be challenging. After all, most of their adult lives have been spent in a focused pursuit of admission into veterinary college. Moving away from this singular goal and exploring their sense of self, their perception of service to others, and recognizing their inner potential to care and empathize with marginalized individuals is desirable both personally and professionally, with significant positive impact for society as a whole.
In a One Health model, factors contributing to each sector — humans, animals, and environment — are studied. Within veterinary medicine and particularly within the veterinary curriculum there is understandably a focus on the animal sector relative to the human and environmental sectors. However, in clinical practice and in community health, equal knowledge of all sectors is required. With Floating Doctors, the outreach experience provides students with the unique opportunity to gain more knowledge, acceptance, and understanding of a marginalized human sector and how the well-being of both animals and owners are intertwined. Through a One Health lens, the increased empathy, compassion, and stewardship of early career veterinary professionals will undoubtedly lead to improved animal and human welfare, and thus improved community health.
Floating Doctors’ One Health engagement initiatives with the marginalized indigenous communities of the Bocas del Toro archipelago include the integration and community-level collaboration of veterinary teams with human healthcare providers. This team approach serves to cooperatively improve the health and welfare of humans and animals, demonstrating that veterinary care can act as a direct avenue to improve health and social service delivery for underserved populations.
Not only do students gain an appreciation for the power of the human-animal bond, but they also witness how it can be leveraged to motivate changes in behavior that benefit both human and animal welfare. By supporting and maintaining the human-animal bond, students also begin to appreciate that their work extends beyond the health and welfare of animals, but also directly benefits the psychosocial and physical health of their clients.
In the early months of 2015, Floating Doctors added another paddle to its ever-expanding Cayuco (wooden canoe) by launching its dental programme in tandem with the flourishing mobile medical clinics. It has always been the dream of Ben LaBrot, the founder of Floating Doctors, to have a long-term dentist join the crew. The need for dental treatment is in high demand but unfortunately very rarely accessible to the Ngäbe communities.
In its inception, the team’s first clinic was set in the mountainous village of Norteno. From dawn till dusk, spanning over two days, 80 patients were seen by our tireless dentists who maintained high spirits despite the failing light and increasingly limited resources. It is this drive and motivation to deliver healthcare in such challenging conditions that epitomises the spirit of our leadership team and volunteers representing our organisation.
Since then, we have visited multiple communities where we are continuously amazed by the extent of dental caries prevalence, especially in young children. On each clinic, we will see an average of thirty patients, many of whom have suffered in pain with toothache or infections for several months or even years! Imagine, or can you remember, the debilitating sensation of dental pain and being without access to dental treatment for that length of time? Our clinic is currently restricted to extractions and minor oral surgery, but with time and correspondence to those with invaluable resources or expertise, we will strive to make Ben’s dream come true.
The development of the Floating Doctors dental programme would not be possible without the support and kind donations from our benefactors and organisations. For this we cannot extend our gratitude enough. We have set a target of $10,000 which, once achieved, would provide all the equipment necessary for a fully functional dental clinic to serve the Ngäbe communities. We have a fantastic opportunity to implement positive changes to the oral health of the communities in Bocas del Toro.
It is a privilege to share this journey with you. Our working environment is such a challenging, exciting, very tiring, but thoroughly rewarding experience. Improving a patient’s quality of life is not based on what procedure or medication I give them, but my ability to show compassion and care to a person where they are expected to expose their problems and fears to a stranger whilst overcoming language, cultural, and social barriers.
Written by: Kevin Lan, Floating Doctors Lead Dental Provider
Blog by Volunteer Doctor Jesus Niebla, MD (United Kingdom)
I am a man who before this trip was scared (well I’d say apprehensive) of heights, mountain paths with sheer drops and free running river crossings.
I was not too fond of thunderstorms either.
In the early hours of the 16th of July I set off with the Floating Doctors on a surgical follow-up appointment. In the UK its normal for the patient to come to the hospital, wait an hour or so and get seen by the surgeon who operated on them, then go home. This appointment was different, we went to them, that’s the fundamental difference in our mission.
But when I say ‘We went to them,” what exactly do those few words mean? We took a high-speed water taxi from 25 miles from Bocas to Almirante on the mainland–it takes about 35 minutes bouncing and thudding through the sea. From Almirante we bundle our way into a taxi, pick up some supplies (water, tuna, rice, condensed milk, Gatorade and the important Panamanian Hot sauce). It takes about an hour to sliver up the shoulder of this mountain motor-way to our first base camp. The scenery is lush, I’m pretty tired from the early rise, but I stil take some time to enjoy it while my team-mates sleep (a wise choice with what was ahead of us).
Eventually we get to our base camp, Pueblo Nuevo. It’s the rendez-vous with our guides and pack horses. We charge up on some rice, chicken and the tastiest avocado I’ve set my hands on. We meet our guides and horses to help take the heavier loads; they ride ahead. The horses effortlessly cut through the path ahead–they go first as they scare any snakes or nasty surprises away. They pick their way up the steep climbs with practiced ease; its what they do almost every day and they know the way better than we do. We find ourselves walking on a parallel and tricky path, crossing an Indiana Jones style bridge (except we’re not surrounded by bad guys and its in fairly good shape, although the odd broken panel wasn’t too reassuring).
We make our ascent, climbing up and walking down the steep- clay-brown-well beaten tracks, but this didn’t make them easier. Our guides soared up the tracks with embarrassing casualness.
In-between the sweat, heat, humidity, knee-deep mud baths, sheer drops and snake shaped branches there was a different assault of the senses, a real appreciation of the beauty of this place. Our path dissected fields through flowing rivers, to the butterflies that garnished the clear, blue-sapphire sky above us. It felt like scenery that was the mostly an inspiration of the Steven Spielberg classic Jurassic Park. At every bend in the trail I expected to see a Tyrannosaurus.
Four hours later, sore legs and sweat soaked we make our 2nd base camp of the trip. La Savana, “The Grasslands” and such an aptly named place. We try and rehydrate and rest, an hour or so passes, and too soon it’s time to find and see our patient. We head off again, although this time only for an hour; I’m relieved at this small amount of time, but the path is much different. It was such a steep incline compared to the other paths. Perhaps it was the cumulative effect of the trip, the dehydration, missing the most important meal of the day (breakfast; I know, schoolboy error), but I think I must have hit the wall as soon as I reached the house where our patient lived. Luckily Ben had a Gatorade, it made such a difference.
This didn’t matter, the fact our patient was pretty much running down the hillside to meet us. His actions and motion answered so many of our questions effortlessly. He was fine, he pulled off his wellington, the amputated toe we came to see had healed nicely. There were no signs of infections and the skin flaps were opposed nicely. There were no problems with his balance or ability to continue with his daily routine, although I expect he is a bit more cautious with his machete.
So we made our way back down to Las Savana, make a few house calls on the way (including ANOTHER machete wound), see some patients with pulmonary TB (surprisingly a clear chest on auscultation). We bump into some National Health workers and have positive interactions regarding sharing the responsibility for the medical treatment of the patients with TB.
Eventually we settle back to our camp, have an impromptu clinic under the village’s rancho and soon meet a 6 year old boy with a tricky problem. His father mentions he has a piece of maize in his ear. Ben attempts to extract it, but we just didn’t have small enough tools (my first Job is ENT; I’ll see if I can borrow a set next time). One part of Floating Doctors’ mission is to bring healthcare to patients, if this can’t be done we bring the patient to healthcare. That is exactly what we decided to do–help with the transfer of this young patient and his father to the local hospital. This would normally mean a good 4 hour walk, a few bus trips and perhaps a taxi, so we would accompany them and cover the cost of travel and any medical fees.
The next morning we set off down the mountain with the corn-in-the-ear boy and his father, thinking that descending it would be a little easier. The horses have the heavy loads and we are pretty much on a continuous descent. We still cross the same rivers, and there a few steep sections, but the sun is a lot kinder than on the way up.
A few hours into our walk back it starts to rain, at first a welcome change. We progress, but the rain doesn’t stop–instead it intensifies; the heavens have opened above us. It doesn’t take long for the well-trodden path to become a quagmire. Now it’s a like playing hotch-scotch, planting one’s feet on anything that isn’t the centre of the path otherwise you’re the stick in the mud–a knee-deep mud bath. The downpour also makes the river crossings a tad trickier, as the water level rose significantly in less than 20 minutes.
I am all up for a bit of a challenge, the mud isn’t too bad, we all get used to it, but it saps one’s energy. There is the odd fall, but nothing too serious to anything other than pride. The quagmire now turns into small rivers of chocolate-milk-mud, and then the heavens open a little bit more and decided to spice things up. A thunderstorm starts, we are about 1-2 miles from Pueblo Nuevo, and the more we walk through the jungle trenches the smaller the gap between seeing the lightning above and around us in the canopy and the sound of thunder. We are walking into the eye of the storm. The pace and urgency naturally pick ups, each snap of thunder signals a small sprint for me, then a lull, a sense of dread and then back to a fast march.
An opening is ahead of us, not only are we void of the “protective” jungle canopy but we have to ascendand cross a high, open hill. I recall saying to Ben and Steve we have to clear this ASAP. All the pain, muscle ache and fatigue from the last and current day of trekking for miles of tricky terrain and river crossing all disappeared, the adrenaline was released with a mighty crash of thunder directly above us and and fight-or-flight chemicals coursed through my arteries and veins…. I sprinted up the hill, I slipped on the muddy slope, I got up. I am on my hands and knees trying to get up this hillside as quickly as possible. The desire to get over this death-trap is like nothing I have experienced before. I crest the hill and slide down on my backside, it looked inviting but a few stones and rocks proved otherwise on the way down.
Only a small stretch of jungle is left, and at last we step onto a concrete path that signals our re-entry into Pueblo Nuevo. Stumbling our way through the village back to the shop where we had eaten before making our ascent on the mountain path. To my amazement the town is bustling with Ngabe who have come down from the mountains to place their vote in the general elections, tightly packed under the tin roofs of the local school to shelter from the storm. It gets more ridiculous–there is a local football match ( Soccer) in the football pitch, at the centre of the school. I make a comment to Steve ‘How could the officials allow this match to be played, the pitch is waterlogged”, the players showed no concern of playing in the middle of a lightning storm…until a lightning bolt hits the ground 30 yards from them…then they scarper like they should have 90 minutes before.
We take a short break from the downpour, under the overhanging roof of a house, and the pain starts to re-defuse through my feet and is interrupted only by the thunder and crash of another lightening strike; this one shrieks and booms onto someone’s roof near by. Unfortunately this is followed by cries and panic. The message got passed through the crowed…shouting that someone had been struck by the lightning.
I turn to Ben; “Let’s go check it out”. We now make our way to two houses about 50 yards apart. These houses are elevated about 2 meters off the ground on wooden stilts. Underneath we meet a ring of 200+ people crowding around an 18 year-old Ngabe woman, crying and in obvious distress. Ben checks her out and she seems ok, just in shock (literally) and hyperventilating with some muscle spasms and pain. As we calm her we here cries of two more lightning-struck victims.
I sprint over to the other house (trying to avoid being hit by the continuous lightning attacks), but she is in another house–apparently they were inside when they got struck through the thatched roof. The crowd surround my patient; they eclipse my light; I can’t see. A few choice words and they let the light in.
I notice that her abdomen is distended. This lady is pregnant, 8 months pregnant. My adrenal glands squeeze their last drop of adrenaline. The baby!
She isn’t saying much; visibly shocked, dazed. So I’m thinking to myself, what do I do, its time to get this woman assessed as best we can and transport to hospital. ABCDE, it all comes back. Her airway is good, she is breathing, her lungs are clear, equal air entry. She is pulse is slightly elevated, with a normal character and volume. Heart sounds are normal. She seems a bit dazed, but is responsive. Phew! I notice she has a zig-zag burn starting on her right scapular, working it way down her back to about L5. Presumably the energy dissipated through her feet as she was complaining of severe tenderness in her ankles.
The third patient was a man who had been struck and hurled ten feet across the grass, and wasn’t able to move his arm. I was worried about compartment syndrome, another condition requiring a speedy intervention.
We needed to get the patients transported to hospital as soon as possible for a full review and appropriate investigations, in particular an ultrasound of the 8-month pregnancy. Practically this would mean hailing down a taxi on the jungle highway, or maybe a bus. Fortunately for everyone, this challenge was made much easier as we met some police officers who were able to drive us in a safe and speedy manner to the nearest Hospital in Rambala, a town some miles down the road from Pueblo Nuevo.
How the story ended…
The little boy with a piece of corn in his ear was admitted and had it removed under a general anaesthetic.
The two sisters who had been struck by lightning were both ok and thankfully so was the baby (although perhaps it will be born with super powers).
The man did not have compartment syndrome and eventually regained arm function.
Soaking wet, tired, feet-blistered, hungry and drained we sat outside the hospital and I realized this is what it takes to provide healthcare to these remote communities. On the long taxi ride back (in clear weather at last), and on the water-taxi back to Bocas in the deepening evening, the fear is now replaced with the drive to help these communities further. After a couple of hours of travelling we arrive back in Bocas del Toro absolutely devastated with exhaustion and satisfaction…and I realize this is just another day for the Floating Doctors.
I’m coming back.
Ah, the Asilo…one of the places we heard about here in Panama when we were still in Honduras. We found a unit seldom visited by a doctor (in a year), but with a wonderful staff of no more than a cook, cleaner and nurse on each of the two 8 hour day shifts and 2 on the night shift. There are 27 patients there, all elderly, ranging from totally mobile to totally bedridden, some without sight, some without limbs, many with varying degrees of dementia—they all have to be fed, bathed, many changed, floors cleaned, meals prepared and cleaned up after…the fact that the floors are clean and the patients are clean and fed is an extraordinairy achievement, but the patients need more attention.
When we got there I thought they were totally medicated…so many of them looked so catatonic…it turned out almost none of them were medicated,
or where very occaisionally medicated. They were just bored and unstimulated, almost into catatonia. It was months before some of them spoke; I came back from 5 weeks in California to find patients that I thought had no power of speech actually talking with me. It was like awakenings, and it isn’t because of medication, it is because of all the time our volunteers and people in the community have spent with the patients there. Many had not been out of the grounds for years, and now walk in town weekly—our friend Javier, a Colombian physiotherapist in town who also works at the Asilo, brought his four horses and our elderly patients dressed up and rode like kings and queens through the streets, looking down around them as if to say ‘So…this is Bocas, you say.’
The mayor sent three trucks and we removed several tons of rusted metal and trash from the grounds and landscaped a little (more to go), repaired two broken washing machines and plumbed 3 in total (the only working one had been filled by bucket), installed handrails in the common area for walking and physio, changed the showerheads to removable handle versions, put a commode chair in the bathroom, created and update charts for the patients, provide medications, and have done our best to provide the additional more advanced care that the staff are sometimes not able to provide.
When we arrived, there was an elderly stroke victim, immobile and unable to communicate, and terribly emaciated and contracted with bedsores
all over. We worked for weeks, doing wound care and working with the staff to use advanced wound dressings we provided and creating turning regimens—our goal not to extend his life, but to allow him to die with more dignity and in greater comfort. At one point he got a chest infection and we stood by to administer oxygen and midazolam and buscopan to make him comfortable as he passed, but he rallied…and subsequently gained 12 pounds and the ability to focus and speak a little (very, very little) before he died quietly one night in his sleep a few months later.
And he died with not a single bedsore on him…that was a victory to me, at a personal level. I hate it when people die with their bodies disintegrating externally around them as well as internally. It is unnecessary, but totally natural for birth and death to be so awkward and difficult…the first time doing ANYTHING is usually awkward and difficult: the first day of school, first kiss, first great loss, first great love, first great adventure, the first and final sunset cruise, and finally, the end of the voyage.
Any ship, no matter what storms it has weathered and what damage it has sustained in a long life of navigating unknown waters, wants to look its best when it pulls into harbor for the last time. There should be dignity at the end, as much as can be wrenched from an unfeeling universe. Not always possible…but always a betrayal not to even try.
My cousin, a physical trainer, just arrived here for a few months…I have another patient in the Asilo who has not walked for 9 years after his stroke. He stood up the other day after exercising on his own, ferociously, with some basic exercises we showed him after we applied a difene patch to his paralyzed knee for knee pain, and he and we found out the immobility was more pain-related and he could move it a little. He freaked out an dhas been exercising like a fiend.
I came back from California and he collared me from his wheelchair and looked me in the eye and said ‘Yo Puede CAMINAR!’ And stood up, giggling like schoolgirl. Sometimes things are too much for me to process when they happen…later at night, especially when I’m writing a blog or making a facebook album of the day, I start to process…thinking about that patient a lot. I want to go for a walk with him before he dies—and he might live for many more years, so if he does, I’d like him to be able to walk, and he REALLY wants it, more than almost any patient I’ve ever seen. I feel tiny beside the strength of his determination.
I tell all my incoming student volunteers (I have my little speech about this prepared): “You are so lucky we have the Asilo for you to volunteer in. Not only does every second you spend there interacting with some of the loneliest people I have ever seen benefit them beyond what you can know, but care of the elderly—and especially in this setting—is where you find out if health care is for you.
“Yes, it’s challenging, the medical issues are very complicated, the patients may have dementia and can be challenging, and you have few resources to deploy except what you can somehow manifest…but beyond that, its where you learn things like ‘are you the type of person who is thoughtful enough to throw a corner of a sheet at least over the exposed genitalia of some bedridden shell of a human during some procedure that leaves them all exposed?’ Or ‘When you lift a frail contracted foot off the bed, do you automatically support the knee out of awareness (to avoid torqueing the knee)?’
“It’s a good place to learn PATIENT CARE…not something everyone can learn, because some aspects of it I just don’t think you can teach. I feel like I have to practice at it constantly…people are afraid of old people…can you learn to look past the rotting shell of their failing minds and bodies to ressurect in your mind’s eye when you look at them the glory of their individual histories? It is like looking at old ships tied up in the scrapyard and neglected, never to leave again…remember that those ships voyaged 70 or 80 years across 2 or 3 of your lifetimes…can you see who they were and what oceans and storms they have passed, somewhere inside the wrinkled, frail bodies awaiting their final voyage?”
I love the Asilo…my volunteers go more frequently than I (I only have 2 hands) these days, but I love going in and seeing my friends there. We need people in the community to each give 30 minutes once or twice a month…come on…an hour a month, that’s pretty good…want to walk patients with us? It is awesome—email us or (better) contact us on facebook if you want to go for a walk with us and be checked out to walk patients on your own. One hour per month…you saw the walkway we all built in La Solucion; a miracle happened because everyone showed up and made it with their hands and time.
Make a miracle happen at the Asilo…everybody give an hour a month, and every patient will be walked several times a week instead of never. They’ll get stronger and be more fit (less pain), and be more mobile (and they HAVE to be, the ones that are bedridden have the worst time of it). Let’s make it happen Bocas!
When I last posted in June, a couple of months in, we had just started to really connect with the various subcultures in the Bocas Province, and some situations we quickly identified for interventional projects were as yet beyond our reach. Now we have many more friends and contacts in the community, and we can tackle much more ambitious projects for far less cost.
• Partnered with local group Operation Safe Water to help transport and install raincatcher systems at local schools when we run clinics
• Arranged CPR certification for the fire department
• Worked with the Ministry of Education to train local high school students as trainers for health education in the community and give them medical work experience by participating in our mobile clinics
• Created pictorial and written information sheets on health issues we have identified and that we make available at our clinics
• Gathered and data-entered over 600 patient health data sets and begun doing surveillance of our own interventions and identifying health issues from the data to help guide our mission activities
• Microfinanced patient transports to care on the mainland and chaperoned them in the hospital system (many Ngobe don’t speak Spanish, and are VERY shy, so they easily fall through cracks in systems)
• Connected with an indigenous Curandero to identify and investigate the plants he uses medicinally and are helping him develop his small botanical laboratory always keeping a lookout for.
• Arranged and executed a CPR and First Aid Seminar for the cruising community in Bocas
• Partnered with the Mayor’s Office to run mobile clinics in conjunction with the government visits to the community
• Partnered with the local Lion’s Club to work in a community they support and help supply the neonatal support unit they built with Direct Relief International supplies
And, as always, sometimes we find situations that are just not right. Por ejemplo…
While I was in California, Dr. Barney found out about a 14-year-old girl with what turned out to be undiagnosed cerebral palsy in a small squatter’s community called La Solucion. I have been told it used to be where the airport is now (right next to a mangrove swamp), and when they built the airport the community moved out onto shacks built on stilts over the mangrove mud.
She comes to land at most twice a year…land is about 100 feet away over the sewage-contaminated swamp (all the homes
have outhouses and sink drains that drain directly into the water below). She has never gone to school…she has a wheelchair, but rarely uses it because she has nowhere to go; she has to be carried over the dangerous footbridge by her grandfather, and she is too big now for him to carry (Noah noticed he has drop-foot also…potentially a serious falling hazard, especially if you are carrying your 14-y.o granddaughter over a wet slippery footbridge). She is COVERED in bug bites…she can’t really swat bugs away or keep moving to keep them off her, and she lives in an open unscreened house on stilts over mangroves.
Her grandparents have always thought they were at fault for her CP because she fell out of bed at 6 months (though she had never crawled, which makes me think it probably was CP at birth)…they have carried that burden and they always worried they would get in trouble if the hospital found out, so they have indicated that she has never seen a doctor.
If I were a Hollywood writer writing for some medical drama, my editor would probably throw me out of the building for it being so unbelievably challenging emotionally and physically…but this is real life…this is somebody’s actual life. Sometimes people ask if I miss ‘the real world’…let me tell you, it looks pretty real from where I’m standing.
We said we would build her a walkway, and now—6 months into our time in the community—we called on the community to help and EVERY level of Bocas society came together to make it happen. Mangrove posts from an indigenous community, lumber and funds and food from local Panamanians and expats, help from boat owners, crew on other boats, locals from La Solucion, local taxi drivers, local restaraunts…at the last minute we even had no trouble rounding up 2 sledgehammers (one from the fire department and one from the fish market, which I sometimes haunt in the afternoons when the fishing canoes come in).
Everyone gave a little (some more than a little), and in 5 hours we sank thirty 10-foot mangrove tree trunks 7 feet into the mud, from the shore all the way to her grandparents’ house. The walkway went on in the next few days, and then this little girl went to shore (we still have some work to do to finish the walkway and make it safer for a wheelchair). I asked if there was anything in particular she wanted to do on shore (which she can see, 100 feet away) and she said ‘Quiero pasier’—‘I just want to go.’
This is my favorite, favorite kind of project…one where the whole community comes together when it learns about a situation like this. When the walkway is done, it will have been done right, with the right material (always seek expert advice) to make it last for many years. No matter what, this girl’s life is going to be changed forever—and here’s the best part: total cost for all the lumber, food for the volunteers actually building the walkway, gas to go pick up the posts from another island, hardware, etc: less than $1000.
There’s opportunities for helping, constantly around us…when we are alone we can help in small ways…but mira aqui, look what we can do when we all come together! Poco a poco para cambiar el mundo.
Please click on any of the images to activate the slide show viewer.
The last time I wrote a blog, an unconscionable number of months ago, we had recently arrived here to Bocas del Toro and I ended the blog excited by what might be possible over the coming months…now those coming months have passed, and it is time to catch everyone up and take stock of what we have accomplished here in.
6 months ago feels like a million years ago…with more long-term volunteers, we’ve been able
to really expand some parts of our project, including self-surveillance. I looked at what we had done—how many mobile clinics, how many volunteers, how many projects, how many patients…it is overwhelming to try and describe. I should either write bullet points, or a 3-volume novel to describe everything since my last update.
Over most of our time here, for example, for every 3 days we were here, we ran one day of mobile clinic work—even counting rained-out days (and it rains 150 inches a year here) and days we were involved in any other kind of activity, whether it was working on boat projects, escorting patients to the mainland to get treatment, holding office hours in our consultorio, working in the asilo, eating, sleeping, or doing anything else. We’ve seen over 3,000 patients in more than 17 communities that we visit on a roughly 2-month rotation across the entire province of Bocas (an area of over 4,500 square kilometers), in addition to all our other activities.
No matter what other projects we get involved in, the core of Floating Doctors is our mobility—even the permanent clinics we are now working to establish are to serve as bases from which to continually run mobile clinics by panga, as we have done everywhere we go. I’m incredibly proud of all my volunteers and my crew for maintaining that level of dedication to work one day of mobile clinic for every 3 days we were here.
We’ve seen a lot of different communities, and noticed that there are enormous clusterings of health issues in different small communities that at a glance may seem similar. Why does one community have an incredibly high rate of obesity and diabetes, while the neighboring community has no obesity or diabetes but has lots of parasites? We have gathered detailed demographic and health data on over 550 patients so far, community assessments on a dozen different communities, and are beginning focused projects based on issues we have prioritized based on the data so far. Results of our first survey project coming in the new year…
We’ve started doing overnight and multi-day mobile clinics—getting two or more clinic days for the price of one day’s travel, since our accommodations have almost always been in the homes of local members of the community, or expats who notify the community that we are coming, house and feed our team, and often allow us to use their facilities to hold our clinic and arrange our transport to work in communities near their homes. I have been overwhelmed by the generosity of the expat and local community here…I have never worked anywhere—in the developing or the developed world—where the community at every level will actually deliver on its promises of support like here. From the Mayor sending trucks to help us cart garbage out of the nursing home, and letting us use his old consulting room to open for patient consults two days a week to the local marina workers who are giving their Sunday to help drive 36 10-foot posts into stinking mud to build a wheel-chair walkway, this is a wonderful community, with many eccentric people (after all, we are here too) and many people with good hearts who have shown us enormous kindness and support for our work here. Thank you to everyone—this is what makes Floating Doctors possible. A thousand hands holding us afloat…
We’ve also joined forces with the Peace Corps volunteers scattered throughout the province;
Peace corps Volunteers have thus far been 100% reliable—individual peace corps volunteers live (very often alone) in a community and work on a project. We got in contact with one, on the mainland, and ran a mobile clinic at his village…it is so awesome to arrive with everyone notified, a place to work, directions, someone to help interpret and to give us the inside scoop on patients we are meeting for the first time, someone to pre-arrange accommodation in the community, and best of all, the Peace Corps volunteers can and do follow up with patients that we have identified as needing more advanced care. This has been our experience with the Peace Corps every time we have worked with them, and we look forward to our upcoming multiday clinics to some new communities we are visiting through Peace Corps, including a Ngobe community way up in the mountains that I have heard a Peace Corps volunteer visited but that he thinks has NEVER been visited by a medical team. Looking forward to that later this week…
Petit-Goave, Haiti–Almost a Year To The Day We First Arrived Here In 2010
This is the overdue final chapter of our voyage from Honduras to Haiti, bringing supplies for the cholera relief and personnel for a string of clinics and villages along the north coast.
After our repairs in Kingston were complete, all that remained was to chomp on the bit while only 40 miles away on the north side of Jamaica’s Blue Mountains a series of storms swept down the Windward Passage and collided with a SE swell across our path. At the first day when the swells and wind subsided, we left Kingston at first light and made all speed for the Windward Passage. Once we got out of the shadow of Jamaica, we encountered the most disorganized sea I’ve ever seen—in the space of five minutes we would encounter NE, SE, W, and N swell…thank god the wind had died or it would have been a horrible bathtub; as it was it was merely uncomfortable until we ghosted into the protection of the Bay of Haiti and at last dropped anchor in Petit-Goave, the first place we ever went for a mission…almost a year to the day that we first arrived in Haiti.
An hour after we dropped anchor, in the dead of night, our first friend from Petit-Goave,
Aniel, came out in a canoe…the next day, we saw dozens of people we knew; we went back to the DesGranges clinic and saw Meomene and ‘Cheeks’ and the kids who were there when we left. The two schools we built are now surrounded by larger concrete structures in mid construction; a larger future school sponsored by Korea, I think…but when we walked up to our little schools, each one was packed with kids and classes were in session as they have been since we built them. That was a great feeling…the pharmacy we cleaned and reorganized, and the day patient treatment room and the minor ops room were all organized and cleaned as when we left, and more rebuilding and expansion was still going on. We left a box of supplies for Dr. Cutler, an MD from L.A. who we arranged to go out ahead of us last year and who is returning to Petit-Goave to volunteer again this year—I think he actually arrived yesterday, as a matter of fact.
It was so different arriving here this time…amazingly, most of the rubble had been cleared, and most of the tents crowding every street were nowhere in sight. Some houses had been rebuilt (in concrete block without much rebar and suspect cement), but we saw hundreds of wood frame and tin roof one-room structures, on new poured concrete foundations from (apparently) a Swiss-led European consortium. More commerce was happening, some small businesses had reopened, and the central park was clear of tents and refugees.
I admit, when we left Petit-Goave after witnessing both the massive problems the
Haitians wake up to every morning and the effects of much of the relief efforts after the earthquake, I was not expecting the level of improvement that we saw. My journey to Port-Au-Prince to drop a volunteer off at the airport, however, was much more depressing…a city imploding on itself, with little visible progress over the past year of funds and relief being poured into it. Petit-Goave’s determination to pull itself out of its downward spiral it gave me a renewed hope for Haiti, a hope that I could see in the faces of all of our friends and the new people we saw.
The best moments for me came during the mobile clinics we ran, on the beach at Fort Liberte and in the ruins of an old French fort back from the coast a mile or so. I saw babies that I had ultrasounded 8 months ago and were born while we were away, patients showed me their thin scars where large machete wounds used to be…when I pulled onto the beach in the first load (two trips in the skiff from the boat to our clinic), the kids in the village saw us coming and ran down the beach yelling ‘Sky?! Rachel?!’ and we were surrounded by everyone we knew and treated in the mobile clinics last year. We wormed everyone again, handed out thousands of vitamins, and saw the usual litany of problems great and small—but we saw one patient in our first mobile clinic–less than 18 hors after we arrived–that made the whole 38 days of struggle and travel to get to Haiti worthwhile.
In the little enclave of cactus on the shore west of Petit-Goave, sitting in the same spot
that we did our very first ever mobile clinic as Floating Doctors, we saw a 6-day old baby with an eye infection from Chlamydia or gonorrhea (or both) acquired during birth. This is a very serious, time sensitive problem–a few more days untreated and scarring develops, blinding the child forever (and cross infection and blinding in the originally uninfected eye are very common). We treated the mom and dad and used several days of rigorous cleaning and washing, and antibiotic eye ointment, and the greatest moment of our return for me was watching the pus-filled swollen eye lose its swelling and turn clear—just a few more days and the baby would probably have been blind forever.
It’s not about saving the day, or being a hero…it’s about timing. It’s about being there, and being available as a resource to people who have no other options. A single patient treated at just the right place and just the right time to prevent a lifetime’s worth of suffering for a baby already born into a hard existence. If we had not been delayed by bad weather and bad fuel on the way from Honduras to Haiti, we would have arrived and departed Petit-Goave for Cap Haitian weeks before the baby was born…and when we finished working around Cap Haitian and returned to Petit-Goave, we would have found a blind 1 month old baby.
Life tends to unfold on schedule…not always the schedule I want, and most of the time I never get to know why things happen just the way they do. But sometimes we get a glimpse of a purpose…sometimes what we endure in life makes sense after the fact, and every moment of struggle and frustration and discomfort and fear during the voyage here suddenly became a price I would pay a hundred times over if it meant being able to be there at that exact moment with everything necessary so that baby will get the chance to grow up with both its eyes working.
Dr. Holly saw the baby and when I wandered over to investigate and the problem became
clear, I though “Ahhhhh….so THAT was why we had to go through that crossing.” If we saw not a single other patient there are people who would say the journey was wasted…the old numbers game; people always want to know how many patients seen (over 5,000 so far), how many vitamins (over a million given away so far), etc…and those numbers are important in making sure the investment of resources is not ‘wasted’…but when I get a patient like that baby, the numbers become meaningless and that one patient becomes, for a moment, your whole reason for existing at all.
To that baby and her parents and to me, it seemed pretty worthwhile that we were there and equipped to help…and we see hundreds of people like this, whose paths cross ours at crucial moments when only a small intervention is necessary to change a life forever.
And with each such patient, our lives are also changed forever and a memory is created that I know I will playback to myself many years from now when my adventuring days have ended and smile and wonder how that little intervention in time played out on the world’s stage ove the years. I’ll likely never know–the years-later effects of what we do aren’t ultimately up to me, but I’ll always remember that we were able to help give people a chance at better lives and futures, and no one will ever be able to take that away from us.
All patient photos used with patients’ consent. Please click on any image below to activate the slide show viewer.
This week saw the first heavy, 3 day long pouring rain for several weeks (of course, while we are trying to load the boat and finish our preparations for departure) and the tying off of many threads we have been following for months…we closed up our clinic in Oakridge, packing everything up and saying hasta luego a mi pacientes. Un momento muy difficile. Thank goodness we plan to return to open the clinic permanently as a satellite clinic, open every day with a doctor and staff on site even when Southern Wind is working elsewhere. Knowing we are coming back after this voyage, and knowing that with what we learned and the relationships we forged on Roatan, we can and will open that clinic, makes it much easier to say farewell. Instead, we say (we are going to Haiti, after all) aur revoir.
We finished off a lot of rainy day projects inside the boat (there are always, always more
projects), and got down to the business of prepping to load—that means taking every item out of its storage onboard, condensing everything, repacking all our medical go-bags (thank you Dr. Holly!), and most important: we took delivery of our 5 pallets of material left over in Miami from our last mission to Haiti (thank you Gary, Donna, and everyone at Roatan Rotary!), and our 40-foot container from Direct Relief International, packed with medicine and equipment for the clinics in the island and distributed the material to 5 clinics and the public hospital on the island.
This is a crowning moment for Sky. To get this container in, it required over 1,000 emails between Sky, the shipping company, Direct Relief International, Joseph Natale from Fundacion Heart Ventures, the customs office, the customs broker, Roatan Rotary, a cross-country trucking company and a local trucking company in Miami and another in Roatan, the warehouse in Miami with our 5 leftover pallets, the Ministry of Health in Honduras, 6 different clinics on Roatan, and Cepudo (a Honduran NGO on the mainland).
The difficulty is not in sending down material—anyone can order a container and have it
shipped down here…but not without enormous import fees. It is sending down material and getting it cleared through customs as donated material without $30,000 worth of customs duties applied that is difficult, not to mention that we wanted to create a conduit so that we could send containers on a regular basis. One time is easy…to set it up to be sustainable is way, way more difficult. It took more than anyone else will ever know to get it set up by Sky, but I will always know and always be impressed how much the people you already love and admire can still amaze you.
In a few months I will begin contacting the clinics again, finding out their needs and getting another request for DRI and container number 2…
In the midst of all this, we still see patients, provided the medical service for the Bay Islands Triathalon (including the kayaks monitoring the swimmers during the first leg), and Dr. Holly—whose training
includes major scene accident management—provided 2 days of training for the Fire Department, following up the training provided by our volunteer Sirin last year.
Dr. Holly showed the firemen a particular extrication trick—when you have a patient with suspected spinal injury from a car accident, you can extract the patient through the back window by lowering the front seat, sliding the board in through the back window and taking the patient straight out. Since we have the use of Gary and Donna’s open jeep, we could simulate the extraction without having to smash a car’s back window. We are nothing if not adaptable.
The weather is looking good for this weekend (pouring rain now)…high pressure pushing down, maybe keeping the low centers at bay over our projected route. Loading the IV fluids tomorrow and the next day…Finish securing the boat for sea…provisioning….and a last good night’s sleep.
Then give me that horizon.
Photos of patients used with patients’ express permission.
Photos of unloading and interior boat construction (pretty much most of the nice-looking photos) courtesy of Dan Chomistek
As we were closing up shop after a busy clinic day in Oakridge, we got a call from the Roatan Zoo—one of the new keepers had been badly mauled by one of the monkeys while cleaning the enclosure. Oh man…after a late night working on the computer and a CRAZY day in clinic I was looking forward to lying down for a while, but when the call comes for help, you have to help–so we grabbed our minor surgery bag and some antibiotics and headed over.
Apparently, the victim had been employed there about two months, and was working (as usual) with the main keeper, who had been with the zoo
for 5 years. They had been in the cages together many times before, and had no problems, but this time the head keeper stepped out to grab some additional cleaning supplies and one of the monkeys decided to challenge the new guy.
While with the head keeper, he had been safe—the head keeper’s place in the monkey society was well established (as boss), so the new keeper got a free pass. But when he was left on his own, one of the males just went for him. He was knocked to the ground and savaged, bitten and clawed all over his legs and his arms and hands; the monkey actually went for his face—all the wounds on his arms and hands are classic defensive wounds. Fortunately the head keeper heard the commotion, ran back and pulled the monkey off (the monkey immediately submitted to the head keeper).
The male in question had been horribly abused in its previous home; it had come to the zoo nearly dead…now it is in fine form; I guess it feels strong enough to challenge newcomers in its little kingdom. Everyone always looks at monkeys and goes ‘Awwww….how cute.” And it is true, with their little human faces and adorable antics, they are pretty fun—but they are also wild animals with motivations all their own, and with lots of strength, agility, speed and teeth and claws!
When we got there, the poor guy was a little shocky, covered in blood, dried monkey saliva, and dirt and debris from the bottom of the monkey enclosure. He was so filthy and crusted that we couldn’t even see where the wounds were. Pretty bad scenario from an infection point of view; monkeys have fangs that can bite pretty deep and inoculate your tissues with their raw sewage-like saliva (pretty similar to human saliva, probably).
I immediately gave him an injection of ceftriaxone and an injection for pain. We used a garden hose (the water at this resort/zoo is filtered and potable) to soak off the filth and dried blood as it would have taken more gauze than we had with us, and been more painful. The hose helped gently soak open the dirty scabs over the wounds, and let them bleed out a little to help clean them. Finally we could see the wounds—lots of them, probably around 40 bites and claw marks. If he hadn’t been wearing jeans, I think he would have lost half the skin on his legs, and if he hadn’t had his arms up in front of his face things would have been a whole lot worse.
After disinfecting and irrigating all the wounds, we salved them with antibiotic ointment, dressed them, and gave him oral antibiotics and painkillers, and fresh bandages for his family to change for him if he got wet. We also started him on acyclovir, an antiviral given as prophylaxis for monkey bites. The next day, all his wounds were clean and dry except for his right hand and left forearm, which were very swollen (and pus was expressed from the hand). We added a second, stronger antibiotic and got him to start bathing his wounds in hot soapy water a few times a day.
It worked—his swelling went down and his wounds are healing nicely. Never a dull moment practicing medicine in the tropics, but most of all I liked that we were able to bring care to his home. The house call is still my favorite consult.
When I was a kid I watched my dad do house calls in Los Angeles…practicing Alaskan small-town doctor medicine in a big city. In my folks’ house, as long as I can remember, there is an old print of a painting of a doctor, circa 1830ish, on horseback with a lantern and black medical bag in the dead of night, riding slowly through a driving rainstorm. There’s no adrenaline rush about the figure; the doctor is not flying down the road, coat trailing behind and sparks flashing from the horse’s shoes on the cobbles.
Instead, the doctor looks cold and wet—can barely see his face behind his upturned collar, peering head through the dimly lit night. He has the air of one doing a job that he is doing because he has no choice, because it is who he is. It would never occur to him that someone else should be the one to go out in the night and go help a sick patient. He goes, and gets cold and wet and more tired (he must be a critical care doctor), because to him, that is what a doctor does. It isn’t even a sacrifice, just a part of his core being. I always felt like that picture captured some of the essence of what being a doctor means to me.
All photos of patients are depicted with consent of the patients.
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