Today’s blog was written by one of our recent volunteers, Dr. Ravi Chokshi, just beginning a residency in Obstetrics and Gynecology.  These are his thoughts and impressions of our 4-day mobile clinic up in the mountains to a remote village called La Sabana, or ‘The Grasslands.”  Over 200 patients were seen, including pediatric and trauma emergencies.  Thanks Ravi!  best of luck in your residency, and I look forward to working with you again.

He was different at first glance. Quieter. Saw more, spoke little and took his time to smile.

“It hurts here” he exclaimed pointing at his 12 year old heart.

I had examined 20 chests that day, listened to 20 hearts. But only his jumped at me as I lifted his shirt.

A heart that had decided the only way to get noticed was to become outgoing. I place my stethoscope and still the squall fighting within. My ears record and my fingers feel for the familiar radial pulse. There is a flaw here.  A Woosh-woosh where a lub-dub should be. I bring over some counsel and we use the portable ultrasound to perform a tropical echocardiogram. What I had heard, we now see. A hole connecting the two atrial chambers of his heart, and a chance to be normal forever taken away.

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By the second morning, we had hit our stride. Awake at 7am with the hum of the village around us.  I wish that I could say that I

slept wonderfully on the hammock. Tied across the wooden beams of the village Rancho, covered in a mosquito net donated by the Lake County Sheriff Cliff Matthews.

I almost did, but the cold from the two rivers that flow around La Sabana got to me.

To build your own bed where the clinic just was. Settle into it with the laughter of new friends around and your mind alive with the memories of the day before you. Of the cold stream water you had bathed in, or the hojaldras and coffee that had started your day. Sleep comes easy and you drift imperceptibly towards it as the days’ labor catches up to you and the hungry river swims around you.

The cold shudders in, and you wake up surrounded by the chatter of excited Ngobe children. A quick breakfast and swim later you are ready for work. Walking back from the river you can already see a mass of patients organizing themselves around the rancho. In 10 minutes a fully functional clinic sits where we had just dismantled our bedroom. A pharmacy lies ready and capable. Our amazing interpreters have already lined up patients, sequestered the roving bands of excited children and started patient intake. I sit with my stethoscope around my neck, a clipboard on my school desk of a chair and try to look ready.

This is impossible.

And we begin! In groups of 4 to 6 the mothers and fathers patiently answer my questions posed in broken Spanish while the kids run around, openly gawking at me and my strange tools. As I address them, smiles break out. They are terribly shy and hide their little faces in their mother’s dresses. But I bring them out and I let them listen to their heart beat through my stethoscope and I see their eyes widen and them calling out their amigos to do the same. ‘Ahh this crazy gringo is funny’.

I hear about coughs and colds, about chronic pain, about diarrhea that just won’t go away. I examine distended bellies and the scars from years of no-see-um bites and battery acid burns from cured cutaneous leishmaniasis. Most of all I see the relief as I dispense Albendazole like candy telling them, “Este Medicamento va a quitar las lombrices de su estomago y su piel”. And I urge them to eat it in front of me. I work in a chain with 4 other doctors, most with many more years of experience than me and I confer with them constantly. I learn to recognize scabies and lice and infected wounds and what treatments we can offer for such. I get called occasionally for my input on obstetric patients, being that it is my area of interest.

Using the Sonosite I am able to show a woman 7 months pregnant her unborn child’s face and lips and nose. The kick she feels – she now sees and she can’t stop smiling. In a place where most of the people have never seen an outsider, a white person, or even a TV an ultrasound is magic and we are a mystery they are too polite to solve.

We are observed constantly. And for good reason. In a place as isolated as this from the rest of the world, we are as alien to them as

imaginable. Taking a picture of the children and showing it fascinates them. Then I realize why. There are no mirrors here, no still water. Their first good look at themselves is thru the lens of my camera.

These are the Ngöbe-Buglé Indians, Panama’s largest indigenous group. After years of historical fighting they were allowed to retain their ancestral lands largely confined to the western rainforests of Panama. Here in their Comarca, they implement their own system of governance and economy.  In terms of healthcare they have a raw deal. A long history of poor interactions with outside groups (pretty much everyone since the first explorers) has left the Ngöbe understandably skeptical of ‘Meriginees’ (non-Ngabe people).  As the mother of a very sick Ngöbe child put it to us, “the hospital is where we go to die.”  Language is another barrier. While the Ngöbe men have reason to conduct business with communities in close contact with the mainland and thus have some Spanish speaking skills, the women and children are different matters. Not being able to speak Spanish in Panama is as isolating as it gets.

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Day 1

La Sabaña, the remote Ngobe village that we have made our way too, is one of the more isolated communities dotting the Chiriqui

province of Panama.

Our journey there begins at 5am from Bocas marina, where the Southern Wind currently rests.

A group of 9 odd, we sleepily catch a water taxi to our first destination – the port town of Almirante. Blazing through the Caribbean on a 200 horsepower boat is enough to get everyone up and awake.

?Costa Rica!, usted? is the banner cry as we disembark.

Ahh Almirante. A hastily thatched together port town created entirely by the Chiquita Banana Company, it is best described as a jump off point to better places.

Brushing off the taxi drivers, we find ourselves in a car on a 90-minute ride to the sleepy little village of Pueblo-Nuevo. A tasty Panamian breakfast of fried bread and coffee awaits us and now we are ready for our hike. Ben has hired horses to carry the supplies up the slope, while we carry only water and essentials on ourselves.  A 3-hour hike when dry, 5 plus when wet and we approach La Sabaña by late afternoon.

La Sabaña – literally translating to ‘The Grasslands’ is a mesmerizing place. Found at the crossing of two rivers, its thatched huts and raised wooden floors are as living artifacts to the age before Panama won the geographical lottery and started collecting revenue from the canal.  The Ngobe here live simple lives, the men work in agriculture and raise animals. The women take care of the children and keep the house, all while dressed in the colorful patterns unique to their culture.

It is here we are most in need.

Day 2:

Along with the storm, comes the call from up the mountain. A child has been hurt severely, on his foot by a self-inflicted machete cut. Ben quickly

dispenses half our group with the general surgeon on a race up the slope. I am part of the group that stays behind, together seeing the last few families waiting to be seen. The number of patients has been growing larger every day. Word has gotten around about us and families have traveled on foot for many hours to see a doctor, possibly for the first time in their lives. I have to remind myself of this, as I quietly ache to learn what is transpiring with our other half.

Hours we wait, the rain pouring down, the darkness absolute. The conversation feels forced, every one’s mind on our missing party and what has transpired with them.

Moments before a search party must be raised, their lights are spotted, little moonbeams making their way down the muddy path. They have returned, soaked to the bone but with stories to tell.

It had been necessary to amputate the 10 year old child’s little toe. Amputate it. In the darkness, working on a wooden floor guided by headlamps.

They had quelled the bleeding, stitched it together and addressed his pain as best as they could. We would return the next day with antibiotics and supplies to redress the wound. To leave supplies and to teach the family to keep the site clean. And a phone number to call, just in case.

Day 4:

By our last night the hammocks come up like clockwork. Clinic today had been a sold out success. Patients came from all around the mountain, with many families walking a day’s journey to reach us. We had worked like a well-oiled machine.

As we pack our boxes for the long journey back, the stories come through.

And its not the number of patients seen that we count, but the tooth brushes we had run out of. The soap we had no more off. The medicine for scabies we had to deny.

If there were patients to count, they were the ones we now had the responsibility of following up on. The 12 year old that needed to see a pediatric cardiologist. The women with suspicious breast lumps that needed mammograms, and the ones we couldn’t quite put a diagnosis on out in the field.

Ben and his crew will arrange transport, appointments with the necessary consultants and provide a voice of advocacy to accompany these patients.

What I have seen here erased all presumptions I had before the trip. We were there to see patients and dispense medicine yes, but much more importantly we were there to build trust. To raise the community up bit by bit. To give out toothbrushes and teach kids how to clean their teeth. To teach mothers to recognize dehydration in their children and how to make ORS. Most of all, to provide the village with an avenue of communication they could rely on when posed with a serious problem.

I had been promised an experience of a lifetime when I signed up to volunteer. I say they undersold it.

Four days I lived alongside the Ngöbe Indians. Absolute cutout from the world I knew and an absolute outsider to this hidden world that time had forgotten. I almost died. I very nearly lived. I fell in love again. I yearned to go on, to live this fantasy of waking up in a hammock with lines of patients to see and a fast flowing river to bathe in. Four days is much too short but somehow felt like a lifetime in terms of lessons learned.

In a few short weeks I will return to the US to train in one of the most developed and technologically advanced healthcare systems in the world. I will learns volumes everyday and gain skill sets I ache to possess. But it will always be in a remote Ngöbe village in the protected area of western Panama where I first really learned the gravity of the promise we make everyday on saying these words, “Me llamo Ravi. Soy su Doctor”.

Added by Ben La Brot:  

“It is from the numberless diverse acts of courage and belief that human history is shaped. Each time a man stands up for an ideal or acts to improve the lot of others or strikes out against injustice, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring, those ripples build a current that can sweep down the mightiest walls of oppression and resistance.” 

–Robert F. Kennedy speech in South Africa, carved in stone on his grave.

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