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Blog by Volunteer Doctor Jesus Niebla, MD (United Kingdom)
Amputation in the field, at the top of a mountain…
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.
What a beautiful walk in good weather…
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.
6 Nationalities Represented in the La Sabana team…
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.
Toe Amputation 1 Day Post-Op
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.
Incredible patient bravery
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.
We start work pretty much on awakening…patients waiting…
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.
Amputation in the field, at the top of a mountain…
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.
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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.
Field Amputation of Small Toe With Digital Nerve Block
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
Morning...Now Get Up And Convert The 'Bedroom' Into A Clinic! Patients Are Here!
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.
Filling Up Fast As Word Gets Around...
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
Most People Living Here Have Never Been More Than 10 Miles From Home
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
Don't Let It Get Above Your Boot Tops! Too Late!!
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
The Second Toe Can Be Saved; The Small Toe Has To Come Off...
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:
He Deserves Access To A Doctor If He Gets Sick!
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.
Our Patients And Friends From La Sabana
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.
"Me llamo Ravi. Soy su doctor."
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