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…
Bocas del Toro, Panama
As always, leaving Haiti was difficult. There is always a sense of leaving things unfinished, no matter how many patients you see or projects you complete. I always tell people, we are not going to go help Haiti. That is beyond our power…but we went to help HAITIANS, and helped many. Leaving is hard…but I comfort myself when I remember that our anchor will drop in Haiti again.
We had an amazingly calm and uneventful passage from Haiti to Jamaica (our 4th time crossing the Windward Passage…it was tolerable this time, I’ll give it that). We ghosted through mirror glass seas 200 miles off the coast on our way south to Panama, a full moon reflected among the stars on a sea so smooth that the horizon was not visible. We caught some fish, slept well, had a whale shark partially breach in our wake, saw pilot whales and dolphins…Jamaica to Bocas del Toro has been by far our easiest and most pleasant transit.
Our arrival in Bocas was marked by the immediate generosity of the expat and local community here. Dylan and Darien on S/V Jackaroo, the owners of the Calypso Cantina at Bocas Marina, helped arrange Bocas Marina hosting us while we are here, welcomed us with a fire dance at the cantina, and have just organized a big fashion show fundraiser to support our time here (blog with THAT story coming soon!). Chuck, Courtney and Rosemary and Dana from Bocas Marina have gone way out of their way to support our mission here, and everyone in the local community has reached out to help us here.
This place is almost purpose-designed for a team like ours: a large population spread out over a large area, mostly accessible only by boat, with little or no access to health care…nearest surgery is an hour and half by fast boat ride…a mammogram is 2 hours away…a very, very, very underserved population (lots of indigenous people who have had a long history of poor interactions with foreigners).
We immediately became involved in several initial activities:
By car (thank you Rosemary!) and by panga (thank you Alcaldia!) we have so far been running mobile clinics for the communities in San Cristobal, Drago, and Shark Hole and have returns for follow up and visits to other communities on the calendar for the next few weeks, with help from expats in the area, peace corps volunteers in the communities, and with the help of the local mayor (the Alcaldia).
Dr. Joe, previously the town’s only doctor before entering politics, visits the outlying communities once a week with a government team (health inspector, education directors, building inspector, etc) and we go with to do a mobile clinic. We have some bigger multi-day mobile clinics coming up; on one we will be carrying five 750 gallon water tanks to a remote series of coastal communities for Operation Safe Water.
Nursing Home (The Asilo):
3 staff (cook, cleaner, nurse) on each day shift to cook for, feed, clean, wash, change, dress, and otherwise care for 25 long-term care residents who are wards of the state, most with few (usually none) family members and no means of support. The fact that the floors are clean and the patients are fed is a huge achievement, but otherwise it is heart-wrenching. There is a 3-inch concrete sill in each door…to go outside, I watched an old man with no legs roll himself up to the sill, climb down out of his wheelchair, lift the chair over the sill, lift himself over the sill, and then climb back into his chair.
Piles of rusting metal and trash and junk fill the backyard, and vultures walk amongst the patients in the fall-hazard garden. There are no handrails anywhere, including the bathrooms. A doctor has not come from the hospital to look at the patients for months, and they have no meds at all. And the patients have no charts at all. SO…we created charts, did full histories and physicals on everyone. Now we can write and document progress notes and exams and studies.
The mayor sent a municipal truck and we filled it three times with garbage and junk, CJ has gathered many cuttings and plants given by other members of the community and begun systematically landscaping the demilitarized zone that was the backyard, we’ve been doing wound care, skin care, walking and exercising the patients, repairing leaking water pipes, changing inappropriate shower heads, providing eyeglasses, and generally trying to improve conditions everywhere we turn. If you are in Bocas and reading this, come by and give us a hand!
Bocas Emergency Network:
We arrived here to find that the BEN (Bocas Emergency Network) was already in existence here—a network of about 50 expats scattered across the area who remain in radio contact to alert and assist each other in emergencies. The name seemed a fit made by fate, so our call sign in the BEN is ‘BEN911’. We have taken a couple of calls through the network, but fortunately none which were serious enough to necessitate an emergency callout. We are working on getting our own panga and programming known safe routes through this maze of mangroves to all the different BEN member homes (which are all located near local villages) into our GPS so with a searchlight we can make high-speed response to emergencies or do fast transit to Changinola (closest place with surgical facilities)
So far here we have had medical students from Israel and Saskatchewan, Canada, an RN and her cameraman fiancé from Australia, pre-medical and nursing students from Duke and Berkeley, an Optometrist living locally who is going to come do monthly prescription clinics (we have glasses), a nurse from Florida who just moved here with her husband, and we have a tropical medicine specialist coming from the UK, a nurse from California, and other volunteers coming throughout the summer, and some of our old volunteers returning too (awesome). It is amazing watching them go through the experience. It changes us daily, and it is fascinating and rewarding to watch people rise to challenges, encounter people and situations which push them past their boundaries, and seek out and develop opportunities to help.
I read about a playwright/director, terrified after an awful dress rehearsal before the debut of his one chance at success, who fell asleep and dreamed that he was scaling a immense mountain peak…vertical walls…no ropes…he, who had always been scared of heights, in the dream is climbing like a man born to the rock and the sky, and as he nears the summit, he loses his grip and slips, hanging just below the summit by his fingertips.
A man on the summit looks down and asks him if he is afraid of failing…and says ‘it is sometimes a mistake to climb; it is always a mistake never even to make the attempt. Sometimes, when you climb, you succeed, and sometimes, yes, you fall…but there is a third option…’ And then the playwright falls. And as he is falling, he realizes what the third option is: sometimes, when you fall, you find out you can fly.
This I believe.
And in this community there are already many hands under us. What do we have in the works? Of course we want to bring in a container from Direct Relief International with equipment and material for the hospital and dispensarias here; we will soon be doing training with the firemen (who do water rescue here also) in Bocas, working with Operation Safe Water to deliver more tanks and equipment for water projects, doing consults using the mayor’s old consulting room, putting a raised vegetable garden in at the asilo, getting some specialists down here, doing more multiday mobile clinics and continuing to return for follow-up…who knows what else? I feel like this is a community in which we can accomplish a lot…it’s an exciting feeling after 1 month; wondering what we will have done here in another few months…
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Nec Aspera Terrent: “Difficulties be Damned”–the Family Motto of Perry Fawcett, Amazonian Explorer
Labadie, Camp Louise, Caracol; Haiti
It has been a very, very busy few weeks…a lot accomplished; we recently treated our 750th patient for this month. That’s an average of 30 patients a day, including minor surgeries, ultrasounds and acting as 24/7 floating urgent care center. In that time, we have also done mobile clinics in Shadda, Coco, Camp Louise and pre-natal vitamin distribution in Caracol and have visited Milot Hospital, Justinian Hospital, and the HHH physiotherapy center and have helped many patients connect with needed specialist care (I got the schedule of all the visiting American specialist teams for the next few months at Milot so I know when and to whom to refer patients).
Pietre, Dave and everyone at Royal Caribbean have been awesome—we are wrapping up
our time here and getting ready to make our way to Panama to work south of the hurricane zone as the season advances, but I am very grateful to RCCL for making us welcome in Labadie and we will miss everyone when we go.
There’s a saying in medicine: “Common things are common,” and at a certain level of poverty some things become VERY common. Scabies, parasites, respiratory infections and fungal infections are common among my patients, but I hate when several such conditions are found simultaneously in all the members of only one family. A mother, daughter and young son came in with terrible scabies, secondary skin infections from scratching, bad worm infestations, anemia, and chest infections…we medically treated all the ailments, but I spent most of the consult working to make the mom understand the importance of washing, cutting the dirty fingernails of itchy children, washing, not drinking coffee at age 5, washing…and washing. Properly used, a single bar of soap can prevent an awful lot of disease, but poor home conditions and poor health awareness are two regular factors in the illnesses of my patients.
We did a mobile clinic by small boat in Camp Louise, a diffuse farming community of a few thousand people living a few miles west of Labadie. We visited the health center there but did our clinic in one of the local schools, treating the school kids and a lot of other children in the neighborhood. We were joined by a nurse from the Camp Louise Clinic, a Doctor, Physio and two teachers and Hannah from the Cap Haitian Health Network. This clinic was a tough one…a crowd of several hundred gathered within minutes; people were trying to literally pull themselves into the room we were working in (we all worked in one room, hot and crowded but impossible to maintain security otherwise). Hannah and the teachers had their hands full trying to keep us from being overrun, but we got through it—as usual in schools, lots and lots of scabies and parasites, and this location had lot of urinary tract infections and bacterial vaginosis in the young kids. Camp Louise is somewhere I would like to spend some time doing health education in the charitable schools there, as the high prevalence and poorer hygiene of the kids with UTIs suggests there might be a special need there.
Aside from the common stuff, the last couple of weeks have also brought us some very
unusual cases, and some unfortunate ones. The one that caught me the most off-guard was when I was consulting with a 96-year old woman (she’s in awesome shape, totally ambulatory) presenting with shoulder pain radiating to the arm. As I was writing “?mild strain?arthritis” on her notes, she told me that she had accidentally picked up some cursed money (people don’t like picking up money on the ground in Haiti, because JuJu men will curse the coins and scatter them around) and essentially been voodoo’d, so I gave her an anti-inflammatory and Noah showed her gentle stretches and exercises for improving shoulder stability. A few days later she came in and thanked us because she hadn’t had to go to a voodoo man to pay to remove the curse; our medicine had beaten the voodoo.
Let’s see…my shark bite victim is all healed up…the kid who came in with his stitched knee all torn open and infected is all healed up, but he’ll have a big scar on that knee for the rest of his life (but gets to keep his leg; it was pretty horrible looking when he came in and we first unwrapped the dirty bandage covering the torn-open, homemade stitches). The other night, just before dinner, we heard a familiar sound…a small wooden boat making its way towards Southern Wind, with a man, a woman, and a young kid with a dark-stained rag wrapped around his leg. He had been cut with broken glass, and a deep, 5-inch laceration on the back of his calf. It was pretty deep, with a lot of fat and connective tissue exposed and swollen with fluid; at first I wasn’t sure if the edges could actually be
closed, but skin is always a lot stretchier than you might think—I washed the wound and sutured it back up, and a few days later the edges had pretty well opposed. Incredibly, the sutures were ready to come out after about 4 days (really—they were already starting to be grown over); I love healthy kids—they heal so fast and bounce back.
While walking on the beach, we met a guy whose upper arm bone was completely fractured 2 years ago—I mean completely fractured, and it was never treated at all. It hurt badly for a year…and then the next year, without healing, it somehow stopped hurting and he retained use of the arm. It’s some kind of one in a million medical anomaly; absolutely incredible. His arm essentially has another hinge in it…if you bend the arm, the broken bone tents up under the skin and the arm bends right at the middle of the upper arm—Noah and I were absolutely shocked; this guy needs surgery to screw the 2 broken bones back together, so we are going to see if we can get the surgery arranged with someone before we leave.
And lastly…some bad news…a small baby came in about 5 days ago, age 1 month. It looked premature; it had been born weighing 6 pounds but had lost half its body weight, tipping the scales at a skeletal 3.3 pounds. It had no fever, no diarrhea, no vomiting, no cough, but hadn’t eaten much at all since birth.
The baby was listless and weak; it looked pretty thin at first glance but when Donna unwrapped it, we were shocked and dismayed at its emaciated body. I will always remember the apathy of the mother, the frustration of her sister…but especially the moment when we were examining the baby for its sucking reflex—young babies, if you stroke their cheeks with the tip of your finger, will reflexively turn toward the stimuli (as when the nipple brushes their face when they are being put to breast). This baby repeatedly turned its head away, almost as if it were deliberately giving up…unsettling to watch.
We contacted the Cap Haitian Health Network and got the mom and baby transported over the mountains to a hospital in Cap Haitian where they tried to feed the baby through a nasogastric tube, but last night, after 5 days of deteriorating steadily, the baby died (and it was only fed for 1 or 2 days through the NG because the mom couldn’t afford more…I found out too late or I would have found the funds somewhere!).
Things like this almost always penetrate my Zen, I’m afraid…it takes a lot of determination to let it go when things
that shouldn’t happen just keep happening, like that poor guy’s untreated broken arm, or the 10 kids with urinary tract infections I saw in Camp Louise, or that woman’s baby, or the hundreds of other things like that that drop in my lap every month. If you have a 1 month old premature baby that has lost half its body weight you damn well get it care right away, not after it has been deteriorating for a month…but that is easy to say, since to get checked or get prompt neonatal care, care has to actually be available and affordable, and this baby and mother didn’t have that luxury.
So when I sent that baby to the hospital, I knew that it was so fragile it could slip away at any moment, but I knew that its life or death was not mine to decide, only to do everything in my power right then to give it a chance, and the universe would decide. The universe chose to take it back. I’d be lying if I said this time I really, really, really am working hard to not be upset that the result I wanted wasn’t what happened. I wanted the baby to have a future, not just a chance, but I can’t give futures…only chances.
I need more doctors and clinicians out here. Come where your training is REALLY needed!
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Part 3 of Our Transit: Cayman to Jamaica
We departed Grand Cayman on a beautiful sunny morning, anxiously clearing past
the eastern end of the island and waiting to see if an unexpected northeast swell would devastate us, but all seemed tranquil with gentle 1-2 foot seas and clear skies. With the calm water, our fuel (having already been filtered through 10 of our filter cartridges) wasn’t sloshing badly, and our port engine was running smoothly. When it did require a filter change it was comfortable to drift forward for ten minutes while we changed filters.
The next day, as we bore further south, we started to take the wind just forward of
the beam. We shook out the sails, gaining another 2.5 knots to the port engine, but as we came within sight of the western tip of Jamaica, waves wrapping around the north AND south of Jamaica were building and converging on our position at 45-90 degrees to each other, and building fast. As night fell, we were well east along Jamaica but still 50 miles offshore, having worn south to use the wind longer. We turned east and pulled the sails down, securing the ship in anticipation of yet another nasty sea coming…and we were not disappointed.
The seas came round close to the starboard beam, and the period shortened as we drove dead into the wind. Fuel started sloshing, and we soon found ourselves dead in the water as the port engine sucked up the sludge that was our fuel. Frantic filter changes continued, with increased urgency each time as we bore closer to the lee shore. We downloaded a weather report through our satphone (tough to hold the antennae southwest in that sea state) and realized that, once again, unexpected bad weather (11-12 foot seas and 35 mph winds) were coming to the windward passage, and we knew that we would be very, very lucky to make it around Jamaica’a eastern tip and pull into Port Antonio on the north side.
As day broke, Sky and I made the decision to divert to Kingston, which we might be able to reach before dark.
As we approached, we were not able to raise any of the Jamaican officials. It was a public holiday. We raised a local boater on VHF who connected us with a retired Evinrude dealer, who lived up the mountains and monitored all marine radio traffic. We rendezvoused with the first boater at a small cay off Kingston. He lent me a chart and pointed out the unmarked location of the
customs area, a small unmarked anchorage, and the Royal Jamaican Yacht Club anchorage, also unmarked and uncharted. Then, our new friend Tony Tame up on the mountain contacted the customs, immigration, health, and port officials, and we made our final, hair raising approach past Wreck Reef’s dangerous lee shore into Kingston’s main channel and the protection of its harbor…what a relief.
Within 2 hours we were cleared in and allowed to proceed to the yacht club, where we dropped anchor and collapsed asleep. We then spent 24 hours on reconnaissance; getting a Jamaican sim card and number for the blackberry, finding and calling stores that might carry the parts we needed, finding and arranging transport into town to search for what we need at stores we had already
contacted. The kind master mechanic and master engineer from the neighboring Carribbean Maritime Training Institute drove us all over town and helped us figure out where to find what we needed. Within 72 hours, we had obtained and installed all the parts that we needed to repair our engine systems (and incidentally, our alternator) and had polished the 400 gallons of diesel in our tanks…opening each of the three tanks’ access hatches, pumping out and filtering all the fuel, scrubbing and vacuuming the sludge from the bottom and then re-sealing the tanks. We finished at midnight, took on fuel the next day and then were invited by the yacht club to wait for weather at their dock.
What a relief! Tied to the dock, everything is easier, and anchor watches don’t need to be set. It will be hard enough in Haiti; it is great that everyone might get a chance to rest now. The weather is driving us crazy…there is a huge high pressure system over the east, sending howling winds down the Windward Passage, and a SE swell meeting it…it is nasty there, and we are heavily loaded with IV fluids.
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Note: This is Part 2 of the story of our voyage from Honduras to Haiti
First, I will say that the first 48 hours of this crossing from Guanaja to Jamaica will remain with me forever as two of the greatest days I have ever spent on the water…so good that even at the end of the second day, we said to each other that we would surely pay dearly for the day we had. And pay we did…I wish we had pictures of the madness that ensued when things turned from paradise to misery, but by then we were working too hard to remedy our situation, and too sick, to pick up a camera.
Those first 2 days, however, we cruised at 7 knots over a glassy Caribbean sea, with clouds reflected in it, catching fish after fish—dorado, tuna, wahoo, longbill spearfish, blue marlin at sunset, barracuda, grouper (when we passed over the reefs of Swan Island on the morning of the second day) and Jacks. One of the most epic and beautiful days on the water ever—but it meant that when I was off-watch (I had the con from 12-4 AM/PM), dawn was just coming so two full days of catching fish almost hourly kept me awake all day, catching only an hour or two in the evening after dinner.
On the morning of the 3rd day, I went to bed around 4:30 AM after my watch, but since my bunk is in the forepeak I feel the seas pretty badly when we are pitching, and I woke to hell…a wild sea, and a cross sea with the wind out of the northeast and the swell from the southeast. We strapped everything down and bore down dead ahead, climbing up the faces of the swells and coming down hard; Southern Wind handles seas on the bow pretty well, but this Caribbean sea is like a bathtub! Every sailor I’ve talked to says it is choppy, unpredictable, subject to sudden changes in weather, and watching the 3rd day of this supposed 7-day weather window dawn to whitecaps and a short cross-swell makes me long for the long rolling groundswell of the Pacific.
Our journey probably would have been merely miserable but uneventful, but 60 miles south of Grand Cayman
and only a day and a half from Jamaica, bad fuel we took on in Honduras (the worst I have ever seen…might as well have put gutter water in our tanks) started sloshing in our tanks and our fuel filters soon became clogged…Ed and Larson spent hour after hour in the engine room shutting down one engine at a time, changing filter cartridges (good thing we stocked up in Roatan with enough to last—we thought—6 months), until one of the canister cartridges grew so hot the metal fatigued and broke, disabling the starboard engine (to run it unfiltered, as we then rigged it in case of emergency, would have seized all our injectors and the engine would have been much more damaged).
When the port engine fuel filter clogged again, as we struggled to change it in the heaving engine room and reprime the fuel system, we turned beam onto the seas and started to roll. I threw lawn chairs tied to heavy lines off our bow to act as a sea anchor and hold our bow to the weather, and Noah, Dr. Holly and Randy worked to bring the sails up as we turned north to try and make it to Cayman. Sky raised a nearby freighter on the VHF, whose radio operator relayed our position and situation to Cayman port authorities and USCG Miami, and the Jamaican Coast Guard. The freighter stood ready to divert and take us off if necessary, and Sky contacted USCG directly on Satphone to update them with our position and situation in case a major rescue should become necessary. It meant a great deal to us that the freighter was willing to divert and rescue us if our ship had been lost; when we were in Roatan we saw a captain on another ship be told by the owner NOT to divert to help a sailboat that had gone up on the rocks on a channel entrance; the captain was very shaken up by this as he felt it was very, very bad karma. The law of the sea is the ethos of Floating Doctors…always stop and help, since you never know when it might be you on the receiving end of assistance
However, because I have a ship that refuses to give up fighting and a crew that can tackle any challenge and
function even under horrible conditions (even if afterwards we all have a series of quiet heart attacks and have lost weight from vomiting), we refused to give up the battle and with the wind sustained at 25 knots on the beam, the sails stabilized us (I immediately felt it in the engine room) and for a while we made 4.5 knots under sail alone (so much for the skeptics! We may not have all the sail Southern Wind had before her mast was shortened, and she’ll never be a racer, but she was a champion that day).
One the sails were up and I saw that we were making headway safely (if slowly) toward Cayman, I don’t remember much more for the next few hours as I think someone made me go lie down. One of the last things I remember is that the port engine had just been restarted (had to be re-primed with fuel every time the filter clogged) I think, and I put my head down on it in the engine room to fall asleep. It was awesome to make the transit with other captains onboard…otherwise I would have had no choice but to remain awake and functional (the most dangerous scenario faced by solo long-distance sailors). I was pretty dehydrated (had had no water for almost 24 hours, had been vomiting, had not eaten for 2 days, and had been awake for almost 4 days…Ed and Larson (and all of us, really) had a similar experience, and we were crazed when we finally pulled in sight of Cayman.
Holly and I brought the boat the last leg to Cayman and Holly (what a trooper) took the helm and let me sleep a little as we stood offshore, waiting for daylight to make our final approach to dock and clear in at Grand Cayman. We knew a mooring was available free, but first we had to visit the customs dock to clear in before we could move to the mooring and finally relax and sleep. I must have looked wild-eyed in the Port Captain’s office but they must be used to it as we cleared in with no difficulty and got onto the mooring asap.
We spent two days in Cayman waiting for the weather to open (or so we and various government and commercial weather prediction services believed it was going to), made a few repairs and tried to recover from the mess and shock of our previous crossing. We didn’t see much of Cayman (saw a lot of the inside of our engine room!) but the water there was beautiful, and it was a shock to be somewhere with good services available. Our next departure, we thought, would see us arriving in Port Antonio, Jamaica to take on some fuel and fix our broken fuel filter and tie up to a dock one last time for a night before crossing the Windward Passage and beginning our mission in Haiti (where we will likely be anchored in poor holding ground of uncertain depth, and it is impossible to completely relax).
The starboard engine could be used in an emergency (though it would surely soon seize if it had to be run), and
the port engine was functioning adequately to make it to Jamaica in good weather. Repairs were more practical in Jamaica, so at the next weather window we sailed for Jamaica on a calm, flat day…that was not destined to remain so for long.
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Here in the darkened back room she sits like a stone- hands shoved under her small thighs, eyes fixed on the worn floor. The muffled noise of the other children playing drifts in like waves through the slatted window– but in this room everything is still. I sit with my hand on her back reminding myself that I am the adult and strong one here– it is not my turn to cry. I watch as the tears run down her nose making perfect circles of darkness on her dirty pants. “I just don’t like it when they look at me while I’m in the shower, but it only happened once”…”It mostly happens to the other girls”. I hear this from all 6 of them….”The boys here hit us”….”we are worked from morning until night and I’m tired”….The room spins as I hold back the choking sobs that are clawing their way up my throat. A knock at the door and a bidding from the house mother and she’s gone– off to the kitchen to prepare lunch for the 23 other orphans. I watch as she pulls herself together, she is 9, she should not know how to hide pain like this. All 6 girls have claimed abuse over the past two hours and here we are left – 2 shells left shocked into silence. I can not show emotion, I can not allow the owners of this hell to see that I know what kinds of evil the night brings here.
Our allotted time is up and we are escorted out under a the watchful eyes of those in charge searching our faces for any sort of recognition “do we know?” “How much did they tell”. The girls pull at my arms as we leave… am I coming back, when, when, when? “Bye Sky, Bye Sky, when are you coming back”? I can see the pleading behind their words… don’t leave me here, please don’t leave me here. I promise them I will do everything that I can.
We get into the car unable to speak , unable to file away what we just saw and heard, left stricken by what people are capible of. They will not allow me access to the girls, I asked to take them once a week– for the first time on this trip there is suddenly “proper procedures” that take months that have to be followed before I can spend any time with these forgotten no named little girls. There is no one for us to turn to. A barrier put in between that has been so far impossible to traverse around– they are money makers who have been taught to shut their mouths for if they speak they are given up to the streets and the ugliness of the sex trade. I have fought to see them, fought to come back… they have my phone number and they call still pleading asking for my return. At night I think of them laying stone faced in their pathetically pink painted bunk beds scared of any noise in the night and what it will bring.
This is the ugliness of humanity- I see it as I toss and turn in my own bed- their hushed tones narrating the visions of their experiences haunting me into wakefulness………..
This week saw the first heavy, 3 day long pouring rain for several weeks (of course, while we are trying to load the boat and finish our preparations for departure) and the tying off of many threads we have been following for months…we closed up our clinic in Oakridge, packing everything up and saying hasta luego a mi pacientes. Un momento muy difficile. Thank goodness we plan to return to open the clinic permanently as a satellite clinic, open every day with a doctor and staff on site even when Southern Wind is working elsewhere. Knowing we are coming back after this voyage, and knowing that with what we learned and the relationships we forged on Roatan, we can and will open that clinic, makes it much easier to say farewell. Instead, we say (we are going to Haiti, after all) aur revoir.
We finished off a lot of rainy day projects inside the boat (there are always, always more
projects), and got down to the business of prepping to load—that means taking every item out of its storage onboard, condensing everything, repacking all our medical go-bags (thank you Dr. Holly!), and most important: we took delivery of our 5 pallets of material left over in Miami from our last mission to Haiti (thank you Gary, Donna, and everyone at Roatan Rotary!), and our 40-foot container from Direct Relief International, packed with medicine and equipment for the clinics in the island and distributed the material to 5 clinics and the public hospital on the island.
This is a crowning moment for Sky. To get this container in, it required over 1,000 emails between Sky, the shipping company, Direct Relief International, Joseph Natale from Fundacion Heart Ventures, the customs office, the customs broker, Roatan Rotary, a cross-country trucking company and a local trucking company in Miami and another in Roatan, the warehouse in Miami with our 5 leftover pallets, the Ministry of Health in Honduras, 6 different clinics on Roatan, and Cepudo (a Honduran NGO on the mainland).
The difficulty is not in sending down material—anyone can order a container and have it
shipped down here…but not without enormous import fees. It is sending down material and getting it cleared through customs as donated material without $30,000 worth of customs duties applied that is difficult, not to mention that we wanted to create a conduit so that we could send containers on a regular basis. One time is easy…to set it up to be sustainable is way, way more difficult. It took more than anyone else will ever know to get it set up by Sky, but I will always know and always be impressed how much the people you already love and admire can still amaze you.
In a few months I will begin contacting the clinics again, finding out their needs and getting another request for DRI and container number 2…
In the midst of all this, we still see patients, provided the medical service for the Bay Islands Triathalon (including the kayaks monitoring the swimmers during the first leg), and Dr. Holly—whose training
includes major scene accident management—provided 2 days of training for the Fire Department, following up the training provided by our volunteer Sirin last year.
Dr. Holly showed the firemen a particular extrication trick—when you have a patient with suspected spinal injury from a car accident, you can extract the patient through the back window by lowering the front seat, sliding the board in through the back window and taking the patient straight out. Since we have the use of Gary and Donna’s open jeep, we could simulate the extraction without having to smash a car’s back window. We are nothing if not adaptable.
The weather is looking good for this weekend (pouring rain now)…high pressure pushing down, maybe keeping the low centers at bay over our projected route. Loading the IV fluids tomorrow and the next day…Finish securing the boat for sea…provisioning….and a last good night’s sleep.
Then give me that horizon.
Photos of patients used with patients’ express permission.
Photos of unloading and interior boat construction (pretty much most of the nice-looking photos) courtesy of Dan Chomistek
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
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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All Patient Photos Used With Patients’ Consent
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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All patient photos and cases used with patients’ consent
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