For me the sea has always been where I turn for inspiration, solace, and wonder. The night I was born I breathed thick salt air and first heard the sound of long Pacific swells rolling onto whispering sand, and from that day my life was held forever in the sea’s net of wonders. My mom and dad were living in a beach motel in Southern California while my dad did his medical residency, and my first steps were on the sand and behind my dad as he made hospital rounds and home visits to patients. I can never remember any time in my life when I wanted to be anything except a doctor and a marine naturalist, and thanks to my parents, extraordinary mentors and opportunities I became a marine biologist and a doctor and have had experiences in both fields that make me grateful to be alive just for one of those moments.
My favorite thing about the sea is that it is not lonely; in the sea I feel connected by the water to millions of people around the world. I imagine millions of people of a thousand colors and languages and religions and nations all floating together in the sea’s embrace and connected across thousands of miles by one continuous, unbroken sea. When we float in the vast sea, only a little of it is holding us up, but that small part is connected to an unimaginably vast and powerful body of water. In the same way, this is how a people are strong. When we say ‘a sea of humanity’ we acknowledge that humanity–all of us together–are as powerful as the sea, which is always waiting to show what it can do.
Like every wave, every life is unique and beautiful, something I have experienced time and again through this voyage. In 2011 we saw our
10,000th patient, and although I am very proud of how many people have received care through Floating Doctors, what I am most proud of in 2011 was that as we expanded our project, we always stayed committed to the individual patient. Time and again, this has ultimately led to our being able to do more for more people than we originally anticipated and I have faith that we will remain committed to the single, individual patient as continue our voyage.
Long before I was old enough to venture over the horizon the last lands and seas had long since been charted, but fortunately the frontiers of health and the sea of humanity offer an endless horizon. Looking out over the Pacific horizon so many years ago I never envisioned that my greatest loves would one day combine in a mobile medical relief team exploring frontiers of health across the living ocean that washes all shores equally. I had no idea HOW I would pursue these two passions, I only knew with certainty that if I did not have them both in my life, I would never be happy, and so I would look out over the water or read Jacques Cousteau or trail after my dad on rounds, and dream of adventures on distant seas and future patients I would see and help.
But all the time a voice was urging me to move forward, always there was another voice…darker, more ancient; a more primitive vocabulary but it didn’t need sophisticated words…it has raw fear, self-loathing, shame, narcissism, and petty angst and selfishness. This voice, all my life, has whispered under my dreams, telling me I will never become a doctor, and never see the seas I spent my childhood dreaming of. Sometimes it spoke with other people’s voices, like during the year we struggled to rebuild Southern Wind after she had been donated to us and some people scoffed and said we would never make it, and it would never work, and we would all be killed and waste all the support we gathered…but here we are. Sky and I lived with fear as a constant companion for the whole tenuous first year of our project, when so often it hung by a thread, but (especially with my sister beside me and many hands outstretched to help us keep going) we were able to move forward, one foot in front of the other, and now here we are…going on a mobile clinic in the morning, more than 600 mobile clinics into our voyage.
I know now that this pessimistic voice I’ve always had spoke from feeling not good enough somehow to deserve attaining my dreams, and although as I got older (and continue to get older) the voice got fainter and fainter (I pretty much ignore it on autopilot now…most of the time), it took many years before I could–as my wise sister says–”Allow myself to succeed” without it being a struggle. We are always our own harshest critics and unforgiving judges, but as they saying goes: ‘You never know if you can climb the mountain until you try (REALLY try).’ And as a wise man said, is it really that frightening to succeed, and is it really, in the grand scheme of things, so terrible to fail? And there is always the third option (my favorite): sometimes when you fall, you find out you can fly (or learn how really, really quickly)–especially if hands are outstretched to help you stay in the air, and your ego (and the dark voice inside us) allows you accept the help that is offered.
The kindness and generosity I have seen people show towards us and to others fills me with hope that the daunting
challenges of our time can be survived. I am immensely proud of what my crew, friends and family, and all our volunteers and supporters have made possible, and incredibly grateful to be able to be a part of this voyage and to have shared it with such extraordinary people.
Even with all its faults, earth is a beautiful planet, and humanity, despite its many, many faults, is heroic. There are heroes all around us; it has been a great honor to work alongside so many of them.
“The world is a fine place, and worth fighting for.”
Check out these pictures; some of my favorite moments captured in 2011.
Please click on any of the photos to activate the slide viewer.
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.
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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…
BE WARNED: THIS BLOG CONTAINS A REAL PATIENT HISTORY OFFERED FOR ADVICE AND SUGGESTIONS, WITH THE EXPRESS CONSENT OF THE PATIENT. THE DETAILS AND PICTURES OF THIS CASE, A PARASITE CASE, MAY BE GRUESOME.
Today during a scorching sunny afternoon, Christmas came the Southern Wind–here’s how:
When we first left Miami for Haiti, we left behind 5 pallets of additional medication and supplies that we could not fit onboard. We planned to return to Miami and pick them up after finishing in Haiti, and then continuing on to Central America.
From Haiti, we connected with Clinica Esperanza and Barefoot Cay Marina in Roatan, so
we came directly here instead of going back to Miami. We saved a lot of fuel and time but it meant we had to ship our pallets here to Roatan. Fortunately, Gary and Donna Evans arranged for Roatan Rotary Club to sponsor the shipping by providing part of Rotary’s yearly donated shipping allotment from Hyde Shipping here on the island. We also had to coordinate someone willing to drive a truck from the warehouse in Miami that was kind enough to hold our supplies to the Hyde Shipping warehouse in Miami…all the while seeing patients, planning our Haiti mission, fueling, securing the boat for sea, coordinating our 40-foot container from Direct Relief International for the island clinics and for Haiti. It has been BUSY.
However, health care is always our primary mandate, and when we are in danger of being overwhelmed by everything we have to do, we ask for help. Especially any clinicians reading this, this patient has suffered significant symptoms for months and has given permission to post his case for review by any of our medical followers.
Please post comments or questions for more details about the case directly on this page where we can all see them and brainstorm together. All posts are visible only after review and approval by Floating Doctors to protect patient dignity and confidentiality.
Patient: 27 year-old Caucasian male; 6’2”, 180lbs
*No prior medical history of note, no medications, no allergies
- Cardio : BP: 125/85, HR 74 (regular)
- Respiratory: Lungs clear, good air entry across both fields, no creps/wheezes
- GIT: Abdo soft and non-tender, non-distended
The patient had spent 7 months in Honduras working as a volunteer co-pilot on a non-profit emergency helicopter service, with frequent trips to the mainland while transporting patients.
3 months ago, a few weeks before his return to the US, he had complained of occasional vague stomach cramps (sometimes acute) and diarrhea. The night before returning to the US, he took a single dose of albendazole and subsequently had what he referred to as an episode of extreme cramping and “explosive worm diarrhea.” The worms he described were 6-8 inches long and very mucous-like. He continued taking a daily dose of 400mg of albendazole for the next few days, but continued to pass similar worms. He went on a strict fruit diet, eliminated fats and although the symptoms seemed to lessen he still passed stringy worm-like strands, some longer than 12” (in the initial days of treatment). After several days, he went to his local doctor and subsequently sent this email:
“I went to the doc yesterday and got a scrip for Flagyl. I never saw the doctor but the nurse
talked to the doc and he prescribed it. I’ve been on it for, now, two days. I’m coughing up some terrible stuff. One time (within the last week), while in the shower I blew my nose in my hands. In the mucus there appeared to be a worm about 1/2 inch long. It was either a worm or the most congealed mucus I’ve ever seen. Figuring I was exhibiting symptoms of hypochondria, I chalked it up as my mind playing tricks on me. Today, about a week later, after taking the Flagyl for two days, I’m coughing up some horrible stuff, which looks similar, but not exactly the same, as the worms in my stool. It’s stringy, if stretched out about 6-8 inches long. From what I’ve ever seen, mucus isn’t generally this stringy with elastic properties. When running the sink full of water, swirling one around rinsing it off, and then picking it out of the water with my finger, it’ll run over my finger like a spaghetti noodle would. It doesn’t look like a spaghetti noodle, (much smaller in diameter) but acts in a similar fashion when running one over your finger.”
He augmented his treatment with Pyrantel Pamoate equine anthelmintic, taking the same dose as for a 250-lb pony (900mg) daily for three days off 4 days, then repeating, and was also prescribed mebendazole 100mg twice daily for three days, then 4 days off, then repeating the regimen for a month along with the flagyl (metronidazole). He also ate enormous amounts of fruit and had a colonic irrigation (though he saw no worms come out during the evacuation, only the next day), and is taking 15,000mg of garlic daily.
He has not had blood work or an ova and parasites study (stool sample). He has been advised to collect one of the worms and bring it to his hospital or GP for parasitology, and to have a full blood count with differential to look for raised eosinophils. Results will be posted as soon as available.
The ‘worms’ pictured do not look at all typical. Could they be some kind of mucous shedding of the intestine post infection or from the treatments he has given himself…even the garlic? If so, what about the episodes of coughing and similar, smaller mucous strings from his nose? He has tried most of the heavy-hitters for parasites…even horse worming medication (not on my advice!).
Does anyone recognize these as worms or other pathology, or have suggestions for further treatment or investigations? The patient has no medical insurance so cost will be a factor in patient ability to comply with investigations. Taking the worm to a doctor so it can be sent to a specialist and analyzed if necessary is definitely the next step, but any advice or ideas would be appreciated.
Our 40-foot container from Direct Relief is supposed to be cleared through customs Thursday!
Then we can distribute everything, load the boat and depart at the first weather window to Jamaica for fuel and back to Haiti!
All Photos (Except The 3 Worm Pics) Courtesy of Dan Chomistek
Yesterday we returned from our first vacation in almost two years…the first time we have been truly out of contact (although we did have Sky’s blackberry) and doing something that was just for us.
Sky, Noah, me, and Dan from ‘Satisfaction Plus’ (our neighbor and erstwhile Floating Doctors cameraman), took the ferry from Roatan to La Ceiba on the mainland. We planned to go to Copan, about 400km inland up in the mountains and site of the famous Mayan ruins.
Oh, man…I don’t even know what to say. If you grew up watching Indiana Jones, and ever fantasized about
exotic ruins from ancient civilizations hidden in the dense jungle, then Copan is exactly as advertised. Skulls, grinning jaws, imposing birds and leering faces carved everywhere…tunnels dug by archeologists showing the temples buried beneath the pyramids…dead kings looking down onto the stone altar where human sacrifice was carried out, and the court where slaves played deadly ball games in which the losers were sacrificed at the end. We sat in the king’s seat at the top of the pyramid and strolled through the ‘Mayan Discotheque’ where the royal family and nobles of the court celebrated.
It was everything you ever imagined…totally and completely AWESOME.
The town of Copan was a beautiful little mountain town set in the geologically tortured hills along the Honduran/Guatemalan border…cobbled streets, red tile roofs. It was cool, without mosquitoes, and REALLY inexpensive. We were only there for two full days, but I could’ve stayed for a couple of weeks. Everywhere you walk in the jungle, mounds of collapsed jungle-covered rubble betray the site of yet another Mayan ruin not yet investigated (they have only found 5 of the tombs of the 16 Mayan kings of Copan).
On our second day, we drove 30 km down a really bad road (torn to pieces after the rainy season, took us an
hour and a half in a big pickup truck) through the narrow valleys of the mountains. We stopped at the Luna Jaguar thermal hot springs…I don’t know if I’ll ever be able to go in another hot spring without sneering in contempt…the most amazing hot springs ever.
A dozen or so rock pools on a steep, jungle covered hillside along a narrow fault through the mountains…boiling, sulfurous water at 176 degrees pouring from the rocks and into the rock pools and sending clouds of steam up through the jungle canopy. We lingered among the pools for hours, until after nightfall when candles were set out, then finally we tore ourselves away and drove back through the jungle night to Copan; leaving in the morning for San Pedro Sula to pick up Holly at the airport.
Holly is our new volunteer and is a Tropical Medicine and Emergency Room Medicine specialist from Liverpool. Holly will be onboard three months, and her timing could not be better since we are headed to Haiti. We got back last night and worked on the boat all day today; Ed is coming back tomorrow, Captain Randy is just back, and we have TONS of preparations to make before leaving.
The cholera epidemic in Haiti continues to kill…we have several other doctors and nurses meeting us in Haiti, and others continue to contact us
to see about coming. This is turning into a big collaboration between us, Partners in Health, the Cap Haitian Health Network, SIFAT (water purification systems), Direct Relief International—I’m excited to go back.
When we left for Haiti the first time, the essential systems on the boat were done but we have continued to modify and rebuild ‘Southern Wind’ a little at a time ever since we first left the dock, and this time we will be even more well-equipped than our first trip. We will be working along an area of over thirty miles of coastline, so we will have to be mobile and adaptable…and that’s what we designed our project to do. This time we may well have our team split up and working in several locations at once, so this is going to be a real challenge.
Plus, we also have a lot of patients still to see here on Roatan while we prepare for Haiti…going to be a CRAZY couple of weeks, but the countdown to Haiti starts today!
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All Pics For This Blog Courtesy Of Dan Chomistek
Medicine in developing nations is, most people would probably agree, substantially different from medicine in developed countries. Still, there are many aspects of the health care experience that seem to be universal, shared by ‘have’s and ‘have-nots’ alike. For example, the prospect of surgery under general anesthesia is daunting whether you are having it at the world’s most advanced hospital or in a temporary medical mission surgical tent.
And of course, men, women and children of all ages all hate getting injections (except for little old ladies, who—in every country I have ever worked in—take injections and other potentially uncomfortable procedures pretty much in stride). This week marks the end of our management of one particular patient whose experience made me think about the parallels in health care experience that are shared by patients worldwide.
One day a few weeks ago we had returned to the boat after a long day in clinic, and a 43 year-old
guy walked up to the boat asking if we were the medical doctors and could he consult with us. We invited him aboard, and I immediately noticed he was taking small, tentative, shuffling steps and was bent forward slightly from the waist, pressing his right hand over his bladder. He told us that 9 months ago, after several months of severe pain, blood in his urine, and repeated urinary tract infections, he had saved up for an ultrasound and they had found a great big 3 cm stone in his bladder.
At this stone’s size, open surgical removal is the indicated treatment, but he could not afford the 60,000 Limpira (about $3,300) charged by the private surgeon he saw, but the surgeon said he would make him a deal—he would do the surgery for 45,000 Lempira if the patient arranged for the surgeon to do it at the public hospital, thereby not using any of his own equipment and resources.
The patient DID arrange permission from the hospital to have the private surgeon operate there, but fortunately the patient came to see us (he had no choice, as 45,000 Lempira might as well have been 450,000; he had not worked for weeks and weeks because of his crippling pain).
I visited the public hospital to speak to the chief of surgery there, Dr. Indira Sanchez. She is a fabulous surgeon; the first night I dropped in to help in the hospital I assisted her doing an open abdominal surgery on a gunshot victim, closing perforations in the colon and removing and directly re-attaching a perforated piece of small intestine (total number of personnel involved in the entire surgery, including me? Only five people; patient did fine). She has great hands for surgery—sure, experienced, and capable. I presented the patient’s case to her, she consulted with him, and booked him for surgery only a few days later.
She gave him the orders for his pre-op blood work and chest x-ray (which he had to get at the private hospital because the public
hospital x-ray was not working), and he went straight out and got the tests all done, which we microfinanced. Then he came back to present his test results to one of Dr. Indira’s team, the doctor sent the patient back to Dr. Indira with his endorsement that he was ready for surgery (which we also financed), and two days later the patient had the stone removed in about 30 minutes under general anesthesia.
He recovered well, and is no longer in agonizing pain all day every day. In a few more days he can go back to work, after over 9 months of debilitating pain.
Pre-op blood tests and x-ray: $80
Open surgery for bladder stone removal: $20
Price for living without pain? Pretty hard to quantify, but it seemed pretty important to the patient!
The whole thing got me thinking about the complexity of health care, and how daunting it can be for a patient to try and navigate
their way through the system—DEFINITELY an experience shared by patients in the developing and developed world. Almost anyone who has ever had to use their health service, especially for something major, can appreciate the confusing nature of going from specialist to specialist, office to office, exam to exam, wondering when the whole process will finally be over.
This case was a classic example of one of the main roles now played by General Practice and Family Practice physicians—that of a guide to navigating the maze of specialists and tests and procedures available in an ever-increasingly complex health care system. As Medicine gets more and more specialized, it will become more bewildering for patients—especially for patients who do not have a wide base of health knowledge—to find their own way through it.
The patient gave us permission to document his whole experience; soon we will put out another short video focusing on his experience with a health care system. I think that people in any nation at any socioeconomic level will resonate some part of his experience with their own history of interactions with health care. Some aspects of being a patient appear to be universal…watch and decide.
In this case, the patient was unaware of how to try and arrange a public hospital surgery and our representation (based on the good working relationships we have developed with many clinicians here on Roatan) was key to the surgery being performed.. Although we assisted the surgery and post-op care, our main role here was simply to take a patient and help guide him through the whole process, making an overwhelming prospect (especially for someone acutely sick!) a smooth series of events resulting in the patient regaining his health.
The other primary role of the GP or Family doctor is to try and help keep their patients well enough that they never have to go to the hospital!
A real highlight of the whole experience for me is that it all happened when my mom and
Grandmother and cousin Ishan and his wife Maria were here visiting us in Roatan. These were the people who have been there from the very, very, very beginning, when Floating Doctors was a wild dream keeping me sane during months of freezing, dreary weather in Ireland, to the year of frantic planning and fund raising, to the year of rebuilding the boat, to Haiti and thence to the shores of Honduras.
Our families have been so supportive…without them this never would have been possible. I was very proud to finally be able to show them what all their encouragement and support made possible; it meant the world to me that they came all the way to Honduras to see us. Love to all of you–fair winds and a fast return.
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On Friday we painted a school in Jonesville, one of the original pirate settlements on Roatan. Last week we visited the school to drop off worming medications for the 54 students there, and while we were there we noticed that the school was in dire need of painting. We spoke to Norma, the lady who runs the school, and offered to come back and paint it. We rounded up some help, got 10 gallons of paint from our friend Joseph’s foundation Intensive Heart Ventures, bought some primer and some brushes and rollers and headed back to paint the school the following week. It was perfect–Norma got the students to clear out the building, their session ended for the season, and we arrived at an empty building ready to prep and paint.
We had Pat and Randy with us (two cruising sailors from SV Homeward Bound who have been
helping us with our clinic), Larry (a longtime expat living in the neighborhood of the school), and four kids from French Harbor that have begun having around the boat. I love having them around; they remind me of Bichal and Yvenson and Jonas and our other young Haitian friends. Noah is always the one the kids gravitate to the most–as he is the most ferocious-looking, the young kids naturally hero-worship him wherever we go, so it is usually Noah that takes charge of the kids when they are working with us. Noah has a knack for connecting with the most at-risk kids, getting enormous influence with them right away and creating opportunities to provide them with tools and new ideas.
Meanwhile, I can’t help trying to fill their heads with all kinds of random knowledge (being a teacher dies hard, and when I have them fishing out in the skiff I have a captive audience for the concepts of biology and ecology I’m constantly spouting to them). Sometimes stuff makes it through their burgeoning hormones and days later I overhear one of them telling another to throw a small fish back so it can grow bigger and have babies so when they catch it later it will be bigger, and there will be more of them. For me, those are great moments.
Friday, when we painted the school, was a great moment for me for another reason. As the chipped and faded
colors were covered by smooth new paint, I looked at the group that had assembled on a small peninsula on an island off the north coast of Honduras…a cruising couple, kids from a neighboring community, an expat, the local teacher, and us. So many people that might never have all been drawn together, all working together to do something for some kids they will probably never meet.
That is one of my favorite aspects of our project…the connections created between people, and so many people doing what they can. The school got emptied and cleaned out by the students, and we repainted the whole school, inside and out in less than 5 hours with some touching up a few days later (ran out of paint and a few folks went back with new paint to finish up the last spots).
I love that the same way our whole project was accomplished was the way the school got painted; the school was like a microcosm for our whole project: a lot of people from all walks of life all did a little (some did a LOT more than a little) and got it done.
And continue to do so…thanks to everyone who helped us from day one to painting the school last Friday!
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Man, sometimes a week brings a flood of minor upper respiratory tract infections, fungus, and the usual small town clinic maladies…and some weeks, the dam opens and all kinds of situations arrive on the doorstep. We did a lot of small surgeries, mostly taking off cysts and dealing with minor wounds, and did loads of ultrasounds (lots of ovarian cysts, some gallstones and bladder stones); but we also had a few more unusual cases come in.
First, there was Missty (yes, that is how it is spelled). She lives on a sailboat with her mom and dad, and climbs all over the place like a wild child. She is the cutest little girl ever—she came in a week after getting her knee stitched up at the hospital; she sliced it about 4 inches across the front on a piece of sharp metal and then tore ALL her stitches jumping down onto her boat/home and landing in a deep knee bend. Then it started to get infected, so it was a green mess when I took off the bandage.
Tough as nails, she let me take out the stitches and debride the wound, then I steri stripped it together and rebandaged it and sent her home with some antibiotics and dressing changes… “No more running around like crazy on the boat for one more week!”
Then a guy came in unable to swallow or drink, and unable to lower his chin because his tonsils were so badly inflamed they were like tennis balls, with another tennis ball sized abscess in his
cheek. He was really dehydrated, so we gave him IV fluids and pumped him full of antibiotics. The next day he was marginally better, so we kept him on the antibiotics and after a few days he could swallow and take liquids. Only his cheek abscess remains, and it is shrinking rapidly.
We had a baby come in with a mysterious rash (see the photos below for the case details)…we did two surgical house calls for minor procedures at a shop run by two ladies in French Harbor. One of the ladies, from whom I removed a ganglion cyst, was in a hurry to get home so she could make dinner for her husband. I told her he should do it for her while her wrist has just had surgery, and she and her friend agreed…and both laughed at what a delightful fantasy it was, and how impossible. Still tough to have two X chromosomes around these parts.
Still, our clinic is seeing lots of patients. It was great to have Megan with us. She set up two of the clinic rooms for acupuncture and treated patients two at a time every day our clinic was open, and was always running all over the island after hours giving treatments in the community. Being able to combine acupuncture with western medicine was great—in the community we serve, there is a lot of stress and post-traumatic stress from abuse or violence, and mental health issues are somewhat of a taboo. These issues are often compounded with some form of chronic pain, usually in the knees or back or feet after years of hard living.
When patients I had treated medically and then referred to Megan came back for follow up, they raved about how much they felt the treatments helped, and I have seen acupuncture be effective way too many times for me to doubt that is has efficacy in a number of situations. I’m not sure I understand why it actually works, but although I would really like to know for my own interest, ultimately I don’t care—I really only care that it works! My dad always says that despite their frequent disagreements, there is one way doctors and lawyers are always in agreement: ‘Ultimately, both are only interested in results!’ Especially doing this kind of remote medicine, a doctor has to be ready to use any tool in the toolbox that can help, and I felt that of lot of patients got a good result from their treatments. A lot of them burst out crying after or during their treatments and shared all kinds of horrific personal tragedies with Megan…it turned out that often they were crying about it for the first time, even horrible experiences years ago.
I also think the patients were really, really receptive to the concept, too. Certainly, against the blend of bush medicine, Obia, and traditional home remedies in common use,
acupuncture probably didn’t seem too out of place, and there was also an element of the ‘well, the doctor has suggested this, it must be a good idea’ kind of thinking I often saw among older patients in Ireland and most patients in the developing world. Although in this case that attitude it made it easier to get patients to accept acupuncture treatment, that same outlook can sometimes put patients at risk of medical error. One way to bring people into more active participation in their health knowledge (i.e., questioning the doctor), is by empowering them with knowledge about their own health, and we spend a lot of time in consults drawing diagrams and explaining people’s physiology to them.
Sometimes, however, one of us becomes a patient…last night, walking barefoot on the deck, the side of my foot kicked the slivered edge of a cut pine board, and a giant splinter wedged itself into the bottom of my foot. It was wedged in deep and barbed like an arrow, but after I anesthetized it Noah and Sky got a scalpal and some forceps and pulled it out. Man, it sure is sore today…going to go soak it in salt water before showering tonight.
That’s when you know you have an awesome sister…an awesome sister is one who will hold the light for you when you have to inject yourself on the bottom of your foot, which is pretty much exactly like you imagine. So much is happening all at once—we just found out there is a possibility we will be going back to Haiti to help with the cholera outbreak, we are investigating ways to keep the Oakridge clinic operating on a permanent basis, we are coordinating containers of medical supplies and gear from California and Florida to Honduras, and in our spare time continuing to improve and strengthen Southern Wind.
With this much on our plates, I sleep a lot better knowing Sky and our crew are facing this with me.
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Last week we managed to get a weather window permitting us to visit Isla Guanaja, about 30 miles east of Roatan. This island, which was heavily damaged by Hurricane Mitch, has only one small Centro de Salud public clinic, and only one doctor for the 10,000+ people living on the island. We plan to visit again on our way south towards Panama and drop off a shipment of medical supplies, so this was our chance to visit and see what the particular needs of the community are and what the clinic could really use.
We left from Oakridge at dawn, around the corner from our little clinic there. We were fortunate to hitch a ride with Captain Larry from East End Divers; when we come back here in our ship we will have already been over the ground once with Captain Larry. Now we know where the safe approaches are, where the anchorages are, and how the winds and currents normally run. As it happens, Captain Ed talked to the mayor of Bonacca Cay (the largest settlement on Guanaja) while we were there and managed to get us secure dockage when we return, so it was a very helpful trip!
There is no better way to understand the needs and capabilities of a clinic than to roll up your sleeves and get to work in it, and since we had contacted the
Centro de Salud in Guanaja to let them know we were coming, we had a long list of patients waiting when we got there. On islands, sometimes particular genetic conditions become very prevalent in the population, and we saw a lot of diabetes and high blood pressure–perhaps not surprisingly, we also saw way more obesity on Guanaja than on Roatan.
Whenever I have patients with high blood pressure, I treat with advice on how to lower blood pressure combined with medication to control their blood pressure. Sometimes I see patients on expensive brands of blood pressure pills that they can only get on the mainland (if at all) or can’t afford, so they end up with their blood pressure intermittently controlled and rebounding. The Centros de Salud nearly always have some basic blood pressure medication, so I always try and change people onto medication that they have access to or can afford rather than some of the things private doctors put people on when they can afford to go to one.
Our volunteer acupuncturist Megan did 24 acupuncture treatments, mostly for chronic pain, insomnia, neck pain, and anxiety. The patients really took to it; several came for a second treatment on our second day on Guanaja. Noah saw a lot of adults and kids with poorly healed fractures and soft tissue injuries, and spent time with them teaching exercises to improve their flexibility, support weakened joints and regain strength and flexibility. With our ultrasound, we drew a lot of pregnant women and we ended up distributing over 6,000 vitamins.
As well as diseases, bumps and scrapes that are common to both the developing world and developing nations, we did a house call on a 24 year-old man who weighed 450 lbs and had a huge, painless swelling of his lower right leg developing over the last couple of years. After examining it and talking to him, I am pretty sure he has filarial elephantiasis, sometimes mistakenly called ‘Elephantitis.’
Elephantiasis refers to huge amounts of lymphatic fluid (the clear stuff that makes your organs all wet and shiny looking and that seeps out of your skin
when you get a bad graze) getting trapped in some part of the body, very often the legs or genitalia. If the lymph glands in your body (little balls of immune tissue that your lymphatic fluid seeps through to be filtered) get clogged, the drainage of lymphatic fluid from that part of the body can be blocked and enormous swellings can occur.
Over 120 million people in 80 countries suffer from elephantiasis, primarily in the tropics and with a very high incidence in parts of Africa. There appear to be two kinds of elephantiasis;
one caused by persistent barefoot contact with irritant volcanic soils (particularly in east Africa), and another caused by the parasitic filarial worms like Wucheria bancrofti. Transmitted as larvae in the saliva of mosquitoes, Wucheria nestles in lymphatic glands and blockage of lymphatic flow occurs.
The swelling is painless (though physically and socially debilitating), but crusting and thickening of the skin (probably in part to the victim’s own immune response to the parasite) can result in secondary infections, and the stretching of the skin can cause itching. Rigorous moisturizing, cleaning, washing and drying of affected area is helpful for avoiding secondary infections and other complications, and the worms can be treated with Diethylcarbamazine, Ivermectin, Metrifonate, Suramin, Mebendazole and Levamisole, but most of these are most effective against larval worms and do not get all the adult worms.
Doxycycline over 8 weeks has shown great success at eliminating both larval and adult forms of the worm (possibly by killing the symbiotic bacteria in the worms), but that creates its own special problems. When the worms have been killed, their dead bodies nestled in the lymphatic glands can cause a massive anaphylactic reaction–you could break out in a rash, your blood pressure could collapse, and your throat and airways could swell shut. These symptoms can be treated with antihistamines and steroids, but if the reaction is severe, a patient might have to be intubated.
With the patient we saw on Guanaja, this could be a real problem. Because of his weight, his neck already has a lot of compression on it (and a tracheotomy would sure be hard, as would
IV access) so intubating if his throat started to swell to that level of danger could be a real nightmare. I am going to inquire about whether the initial dose can be done in the hospital on the mainland with an anesthesiologist present–maybe not necessary (prophylactic steroids, antihistamines, and IV access and nebulizer beforehand might be enough) but I don’t think the risk is worth it. I’d rather he was inconvenienced by a long trip to the mainland to have his first doses in hospital only to have nothing bad happen, than to have him risk it at home and be inconvenienced by his own funeral.
If any doctors reading this have more experience treating elephantiasis with doxycycline, please contact me if you have any advice or suggestions. I plan on seeking many expert opinions in my search to find a solution for this young man. Even if the worms are safely eliminated, the swelling may be difficult to get rid of (though massage and compression bandaging can help), but I really want to find a way to get this guy treated.
This is the problem with remote paradises, especially very, very poor ones. The sunrises are beautiful, like this one on our way to Guanaja…but sometimes care for a problem that can be taken care of with some basic treatment is an impossibly long way off. By the time we come back to Guanaja on our way south I want to have a solution for this guy.
Please click on one of the thumbnails below to view a slideshow of pics from our trip to Guanaja
All pictures of patients used with patients’ consent
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