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Chris assisting Dr. Dan
As if partaking in a 4 day jungle clinic, searching the jungle for a girl with cleft palate, and showering in the river weren’t exciting enough, I had the privilege to partake in canine facial surgery.
Dr. Dan instructing the medical volunteers
We stumbled upon an older black dog with a huge mass around it’s eye on our way back from clinic one day. Instinctively, one of the volunteers brought him back to see Dr. Dan, the resident vet. After several x-rays and physical examinations came up empty, Dr. Dan decided to put the dog under in order to get a better look at the inside of this mass.
Here, Dr. Dan encouraged any willing volunteers to join in on this learning experience. We each took turns intubating the dog as it’s very transferable to humans. After surgically assessing the mass and surrounding bone, Dr. Dan opened the floor for medical discussion on what the diagnosis was. We determined that the dog had a tumor that stemmed through the dogs skull and in through the roof of it’s mouth.
Canine surgery
During the restitching process, Dr. Dan used this as an opportunity to teach proper suturing techniques and allowed us to complete the surgery ourselves. I came here to help treat patients, but never expected that my first surgical patient would be a dog! My experience with Floating Doctors has been filled with the unexpected which makes each day a new adventure.
– Chris Bitcon Floating Doctors Volunteer -
This week we have a blog post from UCI med student Lauren Sims. A group of UCI students came to us to work with the parteras (midwives) in some of our communities. In today’s post she talks about some of the patients she saw and what she learned in her time with us.
-Kim Olpin Operational ManagerLauren and fellow UCI Med student Kate Horn working hard during a clinic.
At Floating Doctors clinics you are not presented with your typical American patient in a shiny white hospital room or doctors office. You typically find yourself with an indigenous Panamanian Ngobe under a “rancho” (a typical outdoor patio covered meeting place in these communities) sitting in old wooden school desk chairs. This might be their first encounter with a medical professional.. they might have walked a day or more to be at the clinic… some only speak the traditional “dialecto” of the Ngobe and need a Spanish translator. No matter their circumstance or reason for presenting to the clinic they are all extremely grateful for our presence in their community and in search of an answer to what is ailing them.
UCI students with Dr. Ben in Quebrada Sal.
I encountered some interesting cases. I saw a young child with Leishmeniasis in a remote Panamanian community in the mountains. I performed an ultrasound on an infant who was failing to gain weight in the first few weeks of life for an unknown reason. I saw an older woman with a sixteen year history of hyperthyroidism and severe exopthalmos. I measured a blood pressure of 238/192 in an older gentleman who most likely had an adrenal tumor. I visited a pregnant woman with a history of preeclampsia in her home to do an ultrasound. I saw a child with impetigo and another with Herpes virus that covered the entire right side of his face. I listened to breath sounds of a seven year old with TB. I examined a three year old who most likely had a stroke as an infant and could not use his left foot or left hand or talk.
Lauren with some young Nogbe kids.
I learned first hand about the barriers of access to health care for these patients. Some were not able to get medications or make it to the hospital because they lacked the funds. Others would have to walk a day, take a boat for a few hours and then a bus to reach a hospital that might not even be able to treat them. Some distrust the health care system because of a previous bad experience or a story about the hospital that quickly spread through their small community. My time with Floating Doctors showed me how the health status of the community members in these remote areas directly reflects the prosperity of the community. They deserve access to health care and I am very grateful for the opportunity to be a part of a medical team that reaches out to these isolated Ngobe communities. The patients I have visited with in Panama as a medical student will forever hold a special place in my heart as I continuing my training and career.
Lauren and fellow UCI med student Christy Tabit showing off their newly decorated scrubs.
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At the end of August we held our first multi-day clinic in the community of Rio Cana. It is one of the most remote communities we have ever been to. While we were there a new mother became gravely ill and had to be evacuated. This is the story as told by Dr. Kim Wilson.
-Kim Olpin Operational ManagerI’m telling this story as a reminder to every one of the amazing and selfless work that floating doctors does every day!
We went to Rio Cana recently. For those of you who haven’t heard of it, it’s a community on a peninsula about 3 hours from Bocas. We had not made it that far before because of the distance and also because it’s situated just up the mouth of a river so accessing it can be difficult depending on the weather and tides. We were all very excited at the prospect of going there and it was incredible. It’s such a beautiful place and the people were amazing. We arrived at river mouth and a boat came to guide us in and we were met by lots of the local people who were as intrigued by us as we were them. We started clinic early the next morning – we weren’t really sure what to expect as it was our first clinic there but it was so busy…we saw 124 people on that first day and 140 the next day! A lot of people had problems with colds and coughs, worms and scabies and then there were the more unusual cases such as ichthyosis, machete wounds, insects lodged in ears and a multitude of other issues. It’s hard to explain how amazing it is to see an entire family, from infants to grandparents to dogs and even a sloth at one stage, but working with the locals is an eye opening and heartwarming experience.
Just after lunch, Ben asked me to see a lady who had given birth 40 minutes previously who was unwell so Dan, Philippe, and myself headed down to her house to assess the situation. The baby was well but mum was dehydrated and fatigued. We put her on a drip and gave her pain medications and sat with her for a couple of hours and by the time we were leaving, she was drinking tea and had perked up a lot. We went back to clinic where we were run off our feet well into the dark hours. It must have been 8.30pm by the time a man came to say that the lady who had given birth had taken a turn for the worse. Ben and I went to her house to assess the situation and it was honestly a shock to see her this time. She was pale, sweating, staring into space and had a heart rate of 126 and a blood pressure of 80/56. For those of you who are not medically trained, this is not a good sign, she was having a massive post-partum hemorrhage.
The Floating Doctors team working together to evacuate the mother.
It was clear at that point that this lady needed to get to a hospital but the logistics of this were slightly more complicated. We were 3 hours by boat from the nearest hospital and we would have to use our boat to transport her. Aside from the fact that fuel would cost a few hundred dollars, it would also mean that the team that transported her would miss the morning clinic the following day. I looked at Ben and said ‘she has 8 children and a new born baby’ and he replied ‘we can’t put a price on a life!’ We immediately jumped into action and it was amazing to see how the whole Floating Doctors team pulled together to get that woman to safety. Ben ran to sort the boat, I set up drips and started resuscitating the lady and everyone automatically assumed a role from compiling emergency bags and equipment for the boat to figuring out the logistics of getting this lady out of her small cramped house up the windy, hilly roads to the boat. One thing that struck me during all this was when we were all so focused on the task ahead and I walked into the room where she was and Philippe was sitting on the floor beside her just holding her hand and talking to her. Sometimes in the chaos, we can forget how scared and vulnerable the patient is and just to sit with her and hold her hand and explain exactly what’s happening must have meant the world to her!
From left to right, Philippe, Bethany and Dan.
We got the boat as close as we could to her house and carried her on a hammock from her house to the boat. We were travelling on a small wooden ponga which, for those who don’t know, is an open top boat. We constructed a bed from life jackets and a thin foam mattress and set her down on this on the floor of the boat. The other factor which I haven’t mentioned, was her 8 hour old baby boy. He was wrapped in a thin white shirt and had barely fed since he was born as mum wasn’t well enough. We had to bring him too so we found a small blanket and wrapped him in this and I put him up my top in an effort to give him as much body heat as possible. Many of the locals came to see the boat off and to wish this lady and her baby well. It was pitch dark when we left and we were not allowed any lights as Elvis (our amazing boat driver) couldn’t see if we turned on lights. There was one man at the top of the boat with a torch and he shined it into the air and gave instructions to Elvis on the route to take. We got to the river mouth and Elvis stopped the boat while we waited for a break in the waves. All of a sudden, the man at the top of the boat shouted go and Elvis accelerated. There were massive breaking waves and each time the boat went over one, we were flung 1-2 feet from our seats back onto the hard wood. There were 4 of us on the rescue team, myself holding the baby like my life depended on it, Philippe who literally lay across the woman to try and keep her still and prevent her from being thrown around the boat and Dan and Bethany who took her vitals and held the drip in place to give her the fluids that she vitally needed! I honestly can’t put into words how everyone worked as a team, assumed a role and excelled at it but sitting on that boat getting thrown around the place, I remember thinking that I would trust my life to these people.
Those first 10 minutes in the boat were scary. We couldn’t hold on as we were either holding a baby or drips and at one stage my stethoscope fell overboard. Dan grabbed me for fear I would fall over board with the baby. Finally the waves settled a bit but it was still like we were working on a wooden trampoline! We couldn’t hear the lady’s heart due to the noise, the blood pressure monitor got smashed by the waves and we used only her pulse rate and radial pulse and her degree of interaction with us as markers of how well she was doing. As for the baby, that little boy did not cry or move for the first hour. I was absolutely terrified that he had been hurt by the momentum of the boat or that I had inadvertently smothered him whilst trying to protect him. I couldn’t check because it was too bumpy until we stopped the boat to refuel and the relief to see that little fellah move was incredible.
Dr. Kim checking on the newborn during the boat ride.
During our trip, it also stuck me how amazing the night was. There were so many stars in the sky and the moon was full and bright, there was lightening flashing in the distance and the sea lit up from algae as we sped through it
The trip took approximately 3 hours and we pulled into the dock behind the hospital at 1.30am. The gate was locked and 2 of the guys had to scale a barbed wire fence and run to find help. We got the woman out of the boat and an ambulance brought her straight to the emergency room. We sat outside the hospital for an hour to make sure mum and baby were ok and then headed back to Bocas for the night. Elvis drove us back to Rio Cana at 8am the next morning for the second day of our clinic.
After that, we had no phone reception for 4 days so we hadn’t heard how she was doing. I can’t explain the relief and happiness to hear she was doing well when we got back. I went to Almirante to see her yesterday and walked into the hospital room to see mum and baby alive and well. Mum didn’t speak much but when we went into the room, she looked at me and Sam and gave us the most amazing smile…In that moment, I would have done the trip a hundred more times just to see her smile! Words would not have expressed thanks like her smile did that day – honestly, it reduced me to tears and it’s pretty difficult to look professional when you are crying like a blubbering idiot!!!
Dr. Kim holding the newborn while in looking after the mother in the ambulance.
For me, the whole experience was mind blowing…the way that everyone came together and worked as such a team, no one needed to be told what to do, they just did it. Everyone was selfless and hard working with a common goal- all we wanted was for this woman and her baby to be safe. She’s going back home today and even as I write this, I have tears in my eyes and all I can see is her dazzling smile!
Floating doctors is an extraordinary charity and this is just one small example of the impact that Ben and his team are making on the people of Panama!!
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This week I’d like to share with you our second guest blogger from the Master of Science in Global Medicine program at USC, Lily Sheshebor.
-Kim Olpin Operational ManagerLily on the dock ready to get picked up for clinic.
The Power of Passion
I have always thought that I wanted to be a doctor. I volunteered at clinics, studied rigorously for my MCATS, and dedicated hours to memorizing facts for my pre-med courses. My passion for medicine was evident, yet my drive to continue pushing through the numerous obstacles before medical school was beginning to mitigate. I was tired, stressed, and scared that I would not become accepted. Attending USC for my Master’s of Science in Global Medicine, I was given the opportunity to study abroad in Panama for the summer. Those couple weeks, while working closely with the volunteers of the Floating Doctors, gave me back the energy for my passion. I quickly remembered why I am committed to the world of medicine.
The first “clinic day” that we had was the most memorable experience of my life. I was very anxious the days leading up to our clinics as I had never worked in rural settings nor an international nation. Stories of past clinics included many infectious and contagious diseases that were somewhat concerning and I was nervous that I would let the group down in terms of executing various clinic tasks. Early morning, we were picked up with a small boat and sailed through the beautiful archipelago of islands to reach the community of Cerro Brujo. Wearing our scrubs and carrying bags of equipment up the hill, I immediately felt a sensation of motivation. I realized we had arrived and we would soon be apart of medical access that the individuals of this island greatly lacked.
Getting your nails painted is a popular activity anywhere in the world.
We were asked by the head doctor, Dr. Ben, to split into groups and inform the community that our clinic has arrived. I wanted to tell everyone and split from our group with another student to cover more ground. Since the people of Cerro Brujo only speak Spanish, my years of high school Spanish were paying off as I told the families and children to spread the news. Once the clinic began to commence, the motivation that started earlier grew into dedication. I did not stop working and loved every minute from checking patients into the clinic, beginning a new chart, taking a medical history and vitals, shadowing the doctors, to the overall interactions with the patients. After our clinic was coming to an end, we were able to distribute stickers, paint the kids’ nails, hand out coloring books, and take millions of pictures. The children were one of the most beautiful children I have ever met. Their eyes were so shiny with excitement that they had new friends and memories aside from their everyday lives. I wanted to give everything I owned to these children from every crayon in my bag to the peanut-butter sandwich and chips from my lunch.
Leaving the island that day, I was not only exhausted from the day’s work but I was in love with the power of helping those in need. I knew that my small part with the Floating Doctor collaboration was important but it was not enough. This organization that has dedicated its life to improving and helping the poor communities of rural Panama is savior of these people. These islands lack money, transportation, clean water, adequate housing and sewage, protection, and care. The country does not care to reach out to these communities but Floating Doctors does. The power of passion is why our world has not yet been defeated. The volunteers of Floating Doctors have that passion and have re-inspired my passion for medicine.
Lily and two other USC students making new friends.
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This past summer we had a number of amazing student groups join us in Panama. One of those was from the Master of Science in Global Medicine program at USC. A couple of the students from that group were willing to share their experience with us. Today I have the pleasure of introducing you to Natalie Reyes.
-Kim Olpin Operational ManagerAdorable Ngobe girl from the village of Cerro Brujo
Traveling to Bocas del Toro, Panama to work with the Floating Doctors team has been one of the most humbling and eye-opening adventures of my life. I have always had a passion for working with under-served populations that have limited healthcare access, however, actually being there on these islands with the indigenous populations was a much more gratifying and awakening experience than I could ever have imagined. The amazing personalities of the doctors, volunteers, and villagers that I got the opportunity to work with truly remind me of the reason I have such a strong passion for medicine and reflect the environment I hope to be surrounded by.
Clinic Day
The experience that Floating Doctors exposed me to on my first day of clinic on the islands taught me so much medically and culturally and allowed everyone within our group to find our own niche within the different roles necessary for a successful clinic. After traveling on a boat bringing all of our medical supplies, we arrived at the community of Cerro Brujo and I was pleasantly enlightened to be greeted by many of the village’s children who could not be more eager and excited to follow us around and talk to us. While many stayed to set up the clinic outdoors, I followed two of the young boys who took me around the entire villaeg, finding houses to let the mothers know we were having a free medical clinic in “el ranchito,” in the central part of the village. I was in complete awe at how rural and isolated these people were from the society I am used to in the United States. Seeing how eager and sweet the children are is an experience worth more than words or photos can reflect. Despite hearing stories of past experiences and being aware of what to expect on the islands, I was surprised by the culture shock I experienced. The villager’s barefoot, simplistic lifestyle was such a difficult,
USC Professor Dr. Meindl-Holman treating a Ngobe mother and her young son.
yet inspiring concept for me to understand. I enjoying being able to get to know entire families during intake and I learned so much from being able to shadow the variety of doctors and medical students throughout the clinic day. It was unreal being able to bring an ultrasound machine into the village and show expectant mothers their child. In one particular instance, we were able to show a mother the heartbeat of her child on the ultrasound screen in the middle of an outdoor, crowded, rural “ranchito” and that is a memory that I will keep with me throughout my medical career.
The ability to practice medicine and help people in the absence of modern day access to technology and hospitals is completely remarkable. Regardless how much time and passion I put into volunteering and immersing myself in the culture of these people, what they taught me and the experience they gave me is worth more than anything I can ever give back to them. I truly thank Floating Doctors for giving me such an opportunity and look forward to returning in the future!
-Natalie Reyes
USC Global Medicine student Natalie Reyes (back row, second from the left) poses with other students, USC Professor Dr. Meindl-Holman, and some local children showing off their new toothbrushes.
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3 week untreated leishmaniasis lesion on lower leg
Leishmaniasis (often called “leish” or ‘peeko de vay-hoo-co’ by the Ngabe) is a tropical skin infection found in Panama. In Panama, Leshmaniasis exists in a natural reservoir of sloths and anteaters and is then passed to humans by female sandflies (chitras). Once infected, a small red bump will appear on the skin, turn into a blister, and later break open to form a slowly spreading skin ulcer. The sore is usually painless and not very itchy, and slowly enlarges over weeks. A key feature to look for when diagnosing suspected leishmaniasis lesions is that it is a slowly enlarging skin ulcer that does not respond to antibiotic cream or wound care.
The Nbobe sometimes fight the infection with topical treatments, covering it in battery acid to burn it out, which seems to be effective if somewhat scarring—patients trade a very large, shallow scar of untreated leishmaniasis for a smaller, deeper scar from battery acid treatment. There are some botanic remedies used by the curanderos that bear further investigation, such as applying the hot amber liquid expressed by heating the meat of a raw cashew nut, which we have seen used in some of the communities with promising results.
3 Leishmaniasis ulcers on young Ngabe girl in the Bahia Azul region
As far as western medicine is concerned, there is currently NO effective topical treatment for leishmaniasis, although antibiotic cream can be helpful to prevent a secondary infection of the lesion by other bacteria. The two existing treatments, which are 98% effective, are daily intramuscular injections with antimony (a heavy metal) for up to 21 days, or an intravenous medication called amphotericin B, which is very expensive. Leishmaniasis responds rapidly and well to these treatments.
Because the injections need to be taken every day, early identification is vital—the smaller the lesion, the fewer days of injections will be needed and the smaller the scar will be. If left untreated the initial skin infection can spread, spawning lesions elsewhere on the skin, and involving the mucous membranes (eyes, mouth, nose) with devastating consequences. If you are worried you or someone you know has leishmanisis, it is very important to get checked out as soon as possible.
There is no vaccine or preventative medicine that can be taken for leish, but there is one really good defense that is 100% effective if achieved—don’t get bitten! Easier said than done when it comes to sandflies, but the best way to minimize you risk of infection is to protect yourself: use bug spray, cover exposed skin, and use fans with airspeeds of 5+ MPH to keep insects away. Mosquito nets don’t usually work against sandflies because of their small size unless the net is regularly treated. Place the net in a plastic bag and spray/pour a lot of mosquito repellent (ideally with permethrin, but at least with DEET) into the bag. This will deter anything from even landing on the net and trying to get through. After all, there are way worse things than leishmaniasis that are carried on tiny wings…
Until next time, fair winds and safe travels!
Leishmaniasis scar on recovered Ngabe boy
Resolving leishmaniasis lesion week 6 (week 7 treatment)
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One of Dr. Dan’s canine patients
At last, a veterinarian has come to stay! Dr. Dan is a wonderful addition to the Floating Doctors team here in Panama–it is very hard to work in remote rural communities and see animals riddled with parasites or with horrible injuries that go untreated.
Dan and his wife Cindy moved in right next door to us, and have been incredibly supportive since they heard about our program. We invited Dan to join us on one of our mobile clinic visits to the community of Cerro Brujo about 45 minutes away by boat, and it was like the first time we visit a community–all the chronically suffering patients are brought. Dan had his hands full–a cow had been bitten by a snake, so you can imagine how happy I was to have a great vet!
Worms and other parasites that plague the communities often live in the animals, especially worms, so part of creating healthy communities is ridding the animals of their parasites. Dr. Dan has accompanied us to other communities, including making the trek to La Sabana deep in the mountains, and we are thrilled to have him as part of our permanent team here.
Dan shared an email with us that he wrote to his family back in the US after his first mobile clinic with us, and we would like to share it with everyone to introduce you to a wonderful vet and wonderful human being. Looking VERY forward to working with you and being neighbors! –Dr. Ben
Dr. Dan Ever’s letter:
Dear family and friends,
Dr. Dan’s office in tight quarters!
Thought I would update everyone after one of the greatest days I have had in Bocas del Toro Panama. There is a wonderful organization here called the “Floating Doctors.” They treat the indigenous tribes on the islands of Panama through purely a volunteer basis from people and doctors and allsorts of people from around the world, but mostly the United States.
Dr. Ben started this enormous project, which is his dream in life. The FD work through donations to continue their monumental task as the indigenous tribes have no medical care, scant transportation, and no money. They live off the land and sea. Well, today the FD invited me to go with them to a village on an island about one hour away and thank God I didn’t get seasick of which I am quite famous. A scrawny dog that jumped into the boat greeted us and I immediately said, “My first patient!” Everyone laughed.
Another canine patient riddled with parasites
As we cautiously treaded up the very slippery, muddy, watery paths high up the steep hill slipping and sliding and even getting on all fours, we eventually arrived at the village. Five or six dogs were there to greet us…”more patients,” I exclaim excitedly. While Dr. Ben and his assistants went into various huts to treat people, I was asked to take a look at a cow that had been bitten by a snake in her rear leg. “Sure, no problem! Lead me to her” I said to Juan through an interpreter.
But I hadn’t worked on a cow in about 27 years so…I know nothing about cows! Juan and the interpreter and I went down a steep, muddy path, crossed over a single, narrow log bridge, crawled in the mud under barb wire, then climbed up another steep hill on all fours, more barbed wire, and finally arrived at the family’s home who owned the cow. The cow was laying on her chest when we skidded down another hill to get to her. She promptly jumped up but could not walk well due to a possible hairline fracture in her left ulna/radius area. Although she could still kick the daylights out of a mere human, and of course “gore” a mere human with her horns, Juan grabbed her by the nose and I proceeded to give her an antibiotic injection in her neck with lightening speed due to fear.
Dr. Ben consulting with a peace corps volunteer about issues in the community
Dr. Ben went into their home of which I have included a picture, and he treated a young woman who had scabies. The trip back to the main village was more difficult because of a light rain. I was also called on to look at a pig that was not eating and depressed. Juan grabbed that pig and body slammed him to the muddy ground. Although that pig was sick, he certainly put up a valiant fight and ear piercing “squealing” while I stuck my finger up his butt to retrieve a fecal sample for analysis. Gave him an antibiotic also and it was then another hike to see another pig that had some paralysis in his rear end but could still walk some. Didn’t know what the heck to do to him…yup, another antibiotic injection while the pig was squealing and Juan had him in a headlock.
Lastly, Dr. Ben has arranged a project to lay a water line downhill to a new birthing house for the people. Apparently a large group of students from Yale University are arriving next week and that is one of the things they will be doing…. ha-ha, would love to see the look on their faces when they see the mud, the slipperiness, and the steep, straight-up hills! Get on all fours lest you ski down the Black Diamond of mud! Juan then chopped down some coconuts, sliced them open with his machete and gave them to us to drink to thank us for coming to his village. That was the best drink I have EVER had in my whole life! We were all sweating, exhausted, and sooooo grateful to him for that nectar from heaven.
Another reluctant patient getting dewormed
Before I got into our boat, I told Juan that he was my number one assistant and asked him if he would always help me because I think he is “Superman” (all through the interpreter of course). We loaded our boats again and off we headed to an island even farther away, but the rains poured down and we turned around and headed for home. Dr. Ben asked if I would be willing to accompany him every week to the out islands to help break the parasitic life cycle of which his patients are susceptible. I told him I would be honored just to accompany him and that I have never been “paid” so much in my life. Well, I really can’t believe that I have written such a long email and even send pictures! Hope you are fine and we love you and we will see you next week!
Dad/Dan
P.S. Anyone have some books on pigs and cows?
My first cow patient in about 25 years. Snake bite in rear leg and lame left front leg.
Boat dock entrance to the village and muddy pathway
The family who owns the snakebitten cow
Path through the village. My poor sketchers!
My humble little office
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It had been roughly 48 months since I first began working with Floating Doctors and 30 months since my last day on the Southern Wind. Strangely enough, after spending a semester and half helping to transform a dilapidated boat into a beaming vessel of hope, the feeling of wanting persisted. You see, amid all the hammering, sanding, fiber-glassing, painting, shellacking, presentations, donation collection, and cold-calling, I had not been able to realize my ultimate dream; that is, I hadn’t helped a single patient directly. Landing in Panama, however, punctuated the final sentence of one chapter and penned that iconic first calligraphic letter in the next!
One of few characteristics I share with Ben our fearless “captain” – a sobriquet stolen from the cinematic classic Dead Poets Society – is that I love people. And arriving in a foreign country, for me, is akin to a kid in a candy store. As I jumped from traveler to traveler, I stumbled into a conversation with an off-duty flight attendant who was hitching a ride on my flight. Ironically, her free trip transitioned into funding my transit from Tocúmen International Airport to the hostel where I was spending the night. My mother was a flight attendant with TWA for over 30 years and Elizabeth (the American Airlines flight attendant), like any good flight attendant, took me under her wing and drove me to Luna’s Castle in Casco Viejo. After sleeping for a whopping 4 hours, I packed up and caught a cab for Albrook Airport. To my dismay, I had not accounted for the 1 hour time change and was relegated to posting up on the steps for an hour until the doors opened. Despite the lack of cushioning provided by the pavement, I was enjoying the comfort of cloud nine. In only a few short hours I would rendezvous with my long lost compadres and be reunited with a project that has never been far from heart.
As I stepped onto Bocas soil, I spotted a familiar face. In his usual b-boy stance – only this time he was leant on a weathered bmx-style bicycle – Noah greeted me with a smile and a heartfelt hug (a rare and cherished gesture from a hardened, NJ tough guy). I introduced him to Nereida, a young Colombian woman I met at the Albrook airport, because she was excited to volunteer her time as a translator at our next clinic. As soon as I stepped into the main house, I proudly published my philanthropic smuggling by spilling all 80 lbs of medical equipment and medicine onto the sofa. Their eyes lit up with excitement at the mound of glucometers, vitamins, analgesics, antifungals, scalpels, hemostats, nitrile cloves, bandages, etc that were graciously donated to me by professors, students, and friends at Touro University Nevada (the osteopathic medical school where I am a first year student). What made me happiest was when Ben looked at me with his characteristic calm and poignantly professed, “we are gonna’ help a lot of people with this.” And if you don’t know Ben, you should understand that he is one of those people, in that weirdly inexplicable way, you want to make proud.
After reconnecting with Ben (The Doc), Noah (Mr. Fix-it), and Sky (Operations Extraordinaire) at the main house, I was escorted to my new home for the next 12 days. The “Warehouse,” as they called it, was a non-descript white, rectangular structure that housed the essentials: volunteers & supplies. I met my new roommates and resident techies, Chris and Ishan. Only moments after setting my luggage on the bed, was Noah jingling the keys to the skiff. As we bounced on the mild coastal water chop, I caught sight of a beautiful bow of accomplishment. The winsome ruggedness of the Southern Wind instantly brought me back in time to Palm Coast, Florida. As the memories bum rushed my brain I took note of the exhilaration yet to come. A Dream Realized.
A day or so after my arrival, a sizeable group of nurses and nursing students from UCLA and SFSU joined the team for a 10-day medical mission. The original crew gathered everyone around for introductions over Sky’s famously amazing cooking. Ben and Sky welcomed everyone with a big thank you for donating their time to the Floating Doctors family. Even before the food could settle in the stomachs of our excited bodies, we were packing medical supplies for the upcoming mobile clinic. Vitaminas, analgésicos, y otra medicinas were neatly packed into small baggies with dosage and instructions. As we eagerly inventoried what we needed to bring with us, we shared our stories: how did we hear about Floating Doctors, our motivation to be in medicine, and why we wanted to help provide care to the people of Bocas. We all agreed, “this is going to be an awesome experience!” After talking, inventorying, overdosing on children’s gummy vitamins (they were decidedly useless due to the unforgiving Panamanian heat) and getting one of the few full night’s sleep we were privy to while in Bocas, we found ourselves on our first mission. Asilo, the local nursing home of sorts, is a regular visit for the Floating Doctors and we were all excited for the privilege of spending time with a bunch of interesting old souls. Every person in there, regardless of lost limbs, elevated blood glucose levels, and wandering lucidity, had a heart of gold. They all had stories to share and were so happy to just have someone new to interact with. Aside from doing standard health screenings, I found myself most enjoying the intensely competitive dominos games. Victor, and 80+ year old Bocas native, did NOT like to lose. However, after a few wins he honored me with a non-verbal gesture indicating that I was a worthy opponent. I’ll always treasure our games; slamming the porcelain pieces on the thick wooden table, boisterously declaring our victories and laughing over our strategic blunders.
Over the course of my time in Panama we helped many in the immediate area, in addition to those more than a few hours into the Bocas Del Toro Province. Small towns like Almirente, Las Tables, Changuinola, Popa, and others spread out on the mainland and among the neighboring islands of the archipelago, were all places that were in dire need of help. The one day clinics were amazing because they finally gave me that patient interaction I craved and still crave. It was the multiday clinic, however, that really opened my eyes to the barrier-breaking work that the Floating Doctors pride themselves in. Just before my we embarked on the multiday clinic, I was able to accompany Ben on a small expedition of sorts. Unlike the medical care in the United States, where bureaucracy, fear of liability, and the incessant fixation on time spent per patient are barriers in and of themselves, the care the Floating Doctors provide in Panama is subject only to one unforgiving notion: every patient is a person, and every person deserves to be sincerely heard. Ben, and all those who personally grow from being part of the Floating Doctors, embrace this notion and understand that doing what it takes to improve someone’s life is more than simply writing a script or audibly enduring a few complaints. Delivering care, regardless of location, is about truly hearing the needs and wants of a person and their situation and then making a concerted effort to provide for them. I knew this to be true when Ben took me on a 4.5 hour trek into the jungle to make a house call to an elderly woman who had severe complications from her untreated diabetes, e.g. neuropathy and ulcerations on her feet, bowel obstruction, colic, headaches, and generalized sluggishness. I was able to take her blood glucose and assist Ben in logging her information. We were invited into their home and we did the consult in her bedroom (where she was most comfortable). Unhindered by time restrictions, unremitting insurance regulation, and exorbitant costs, we were able to truly hear her needs and respond accordingly. We were able to make a follow-up visit to check how she was handling the appropriate medication, and to secure an open line of communication with her eldest daughter for routine care.
Once on the multiday clinic in Las Tables, I finally experienced what all of us in the original crew dreamed up so many months earlier. Attempting to sleep to the dissonant, yet seemingly operatic, tunes of feral farm animals while on the floor of a small two room house that had no glass windows, no air conditioning or fans, no hot water, no refrigeration, and limited lighting, was a clear indication that this was the REAL deal! In the morning I shrugged off a stiff neck and traded my bagged eyes for a warm smile because I was about to do what I came to do; I was going to make a difference! We were greeted by a line of about 60 people, ranging from infants to great grandparents, and the line continued to grow as the day went on. No matter how many people we saw, the crowd never seemed to clear. Although I wasn’t a bona fide provider, I was able to take records, vitals, and some diagnostic blood tests. I learned a great deal about the art of the patient in-take, diagnosing, and treating. I learned more in 3 days than I had ever learned in a classroom and I yearned for more. The BNF (British National Formulary) became my bible and I was constantly, and many times frantically, looking up conditions, drugs and their side effects, while trying not to miss the next case. At night I would try and review my notes and make sense of each case – the feeling I got from learning was unfamiliar. I was no longer simply reading a medical textbook, I was investigating a case! However, nothing compared to spending time with the village children. It was a steadfast reminder of why I am certain that pediatrics is the specialty for me.
Even if I was simply giving them a sticker, playing a game, or giving them a reassuring smile, the children always reciprocated with genuine enthusiasm. One young boy, Luís was quick to befriend me and we spent a good amount of time taking pictures, playing soccer (albeit with a flattened ball), breakdancing, and catching countless cases of the giggles. The Road From Dream to Reality Begets Another Beginning. Leaving Bocas was difficult, but I had medical school waiting for me. If I wanted to make a difference in the lives of others and feel the fulfillment of being a physician, I would have to go through the training and earn the degree. My time in Panama with Floating Doctors armed me with an invigorated sense of purpose that I hope to maintain throughout my medical training. Even now, as I study for my first big exam next Monday, I am reminded why I am doing all this. Finally experiencing a medical mission trip with Floating Doctors not only brought things full circle, but has inspired myriad goals for the future. I am working on improving the mobile technology, in terms of hardware, for their patient records. I am working with Touro University Nevada to get them portable computing devices for both patient records and diagnostic purposes, as Ishan and Chris are working hard to create a new online patient database/tracking system (probably not using the correct jargon, but I’m no “techy”). I also plan on bringing a bunch of first year medical students down next summer to experience what I have – there is nothing more motivating! I am so impressed with how much the organization has grown and how it continues to grow. I am very proud to be part of the Floating Doctors and I can’t wait to return! I am already wondering how this project will grow and what my role will be. Floating Doctor’s was born with Ben’s vision and has grown by providing a platform for others to live their dreams. In the end, it seems, every milestone humbly begins as a dream – I cannot be happier because, just like Ben, I love to dream!
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Prepare to deploy…
There comes a time in any journey, when initial prejudices have been shed and before nostalgia settles, when one can see things as they are. I spent the month of October working with Floating Doctors, and for me that moment came while traveling from Bocas town to Kusapin on the panga, the group’s small run-about boat. Ben was at the helm. Tall Greg was at the bow intently listening to a book on tape. Little Greg had claimed the good seat, a plastic chair. I was lying on my back, mid-boat, reading about three men adrift in a tiny raft after their plane crashed in the Pacific ocean. It had been a still and shining morning, but when the sky turned dark I sat up to watch the sea, slightly concerned we might become like the characters in my book. I was more afraid that the increasing wave size would mean we’d have to turn around and I wouldn’t get to visit the fabled Kusapin.
I had extended my time in Panama in order to do one more mobile clinic: five days in Kusapin, a large Ngabe-Bugle community situated at the end of a peninsula jutting out from the mainland and accessible only by boat, a 3-hour ride from our Bocas base. Due to inevitable developing world delays the clinic had been postponed, and because it is not possible just to send a memo, we had to go in person to relay the news. Which is what we were doing when, watching the coast slip by, I had my moment. Being rather simpleminded, my epiphany was not exactly fireworks. It went like this: This is good.
In the preceding weeks I’d fretted over how I was practicing medicine in the clinics we held. I am accustomed to fully
When all you have is your hands…
equipped emergency rooms, the latest technology and medications at my fingertips. At home I check diagrams, doses and drug interactions on my phone, then I recheck them on the computer. I call the neurologist, the urologist, the hematologist. I go the radiologist reading room for further explanation, repeat labs, and have my patients come back for 24-hour follow-up visits. I was not always so neurotic. Prior to studying medicine I had dropped out of university, a few times. I’d worked on dive boats, monitored chimpanzees on an island in Lake Victoria, studied Indonesian in Oregon, called a horse-trailer home. I’d worked for a newspaper in Austria until I quit in order to climb. Then I traipsed around central Africa and worked for magazines. My shining minute was performing at the New York Metropolitan Opera. I rode a horse across the stage, which, although less than 30 seconds in the spotlight, would have been brilliant had I not been forbidden to open my mouth. Despite being tone deaf, I really wanted to sing.
Returning from the mountains; almost home!
The more we engage with the world the more it makes us want to sing, and the more it breaks our heart. At some point I realized it wasn’t enough to dance around stealing stories. I decided I must do more, it was time to become… something. Medicine seemed a good something, so despite the fact that I didn’t know the difference between an organ and a hormone, I applied to Cornell Medical School’s PA Program in New York City. My application was about how I would return with a skill to the places I’d been where there was a lack of even the most basic health care. I wanted to be able to offer something solid to the people who had so graciously welcomed me into their homes and lives. I wrote my essays about malnourishment, malaria, child mortality.
The next couple of years were spent stressing about microbes and molecules and mundane things like exams. Then came the humiliating experience of clinical rotations. There was the New York-Presbyterian cardiologist who interrupted me as I waffled through an EKG interpretation: “I’m a bullshitter too, Antoszewski! But this is someone’s heart you are assessing so I advise you get it right.” To this day, despite having now practiced medicine for six years, I’m haunted and inspired by those great doctors and nurses who taught me accountability. What test have you forgotten Claire? What question are you not asking? I learned responsibility. I also learned fear. It is one thing to play with our own lives, but someone else’s life… First do no harm.
Yet here I was, in remote Panama, seeing patients, not in a white coat but surf shorts, relying often only on hands
Thank goodness it’s strawberry flavored…
and stethoscope. I was handing out puppies instead of pain killers, prescribing antibiotics without the benefit of cultures, assessing limbs and lungs without imaging. There were parrots on the examining tables for crying out loud. I was very happy. I was also rather uneasy. Is it better to do something, even if that something is imperfect, rather than do nothing? I banged my head against this question, turned it over and over in my mind and in conversations. But what if we do harm by not believing in our dreams, by not putting them into action?
Floating Doctors dispenses soap, toothbrushes and vitamins at every clinic. This is a good thing. In the communities we visit worms are rampant leading to dehydration, malnutrition and other complications. The worms can be eradicated with one dose of the medication albendazole. Also very good! The Ngabe think the free eyeglasses are great. Education about water purification, nutrition, and sexually transmitted diseases is desperately needed as the modern world encroaches on even the most isolated peoples. And whether or not there is a hospital, there are always sick people. Should a tumor be ignored because there is not an operating room one floor above us? May be in the over developed word we rely too much on technology. Certainly I have often balked at scanning the head of a child who took a small tumble. A CT scan of the head is equivalent in radiation to roughly 100 chest x-rays, and studies show an increase in the risk of cancers secondary to medical radiation. When I quote this as reason for observing instead of scanning I am asked to imagine what the prosecuting attorney will say in court if the child has an intracranial bleed. There is a trend in the United States to practice medicine defensively. This is not necessarily good. I suppose wherever we work there is room for improvement, and we are constantly weighing the good against the bad.
Painting children purple with scabicide
Like many of those who practice medicine in the world’s neglected places, the Floating Doctors do not have the luxury of MRIs, there is no lab, no specialists waiting at the end of a pager. Where we practice we go on small boats, skinny ponies, our own feet. The donated medicines are carried in plastic bins. But the patients are the same whether seen in a city hospital, a private doctor’s office or during a home visit to a thatched-roof hut in the forest. They have a pain, a concern, or a question they need someone to address. They are pregnant and worried about the baby. They have headaches, constipation, wounds that wont heal. They have a child who is not eating. They have a child who faints. The child who faints has a hole in his heart. Whether or not we listen to the heart doesn’t change the hole. But because he listens Ben can put in motion the steps it will take to get the boy the surgery he needs, and that changes everything.
All of this I thought about, or rather I felt, as we bounced along in the panga that day. The dark had become a storm and the storm drove us to seek shelter on an uninhabited island. Ben drew a diagram in the sand with a stick, made squiggles to show the currents, more lines to denote wind, and an indentation to represent where the ocean floor sloped. Basically, given the conditions it was not safe to make the ocean crossing to Kusapin in our small open boat with its one outboard engine. We had to turn around. I was more subdued on the ride home, but the panga’s loud engine precludes conversation and the sea and salt are conducive to contemplation. I felt a quietening of the questions. My pendulum has had a wide arc, but with Floating Doctors I seemed to be finding a balance. I was remembering why I wanted to study medicine in the first place. It is important to doubt. But we do ourselves and the world a disservice if we forget that shining, elusive something called faith, or hope, or may be just a better tomorrow. After we tied up the panga that evening, Ben said, “Well, we’ll try again tomorrow.” I took a hot shower, and curled up in a hammock to finish my book. Against all odds, having lost everything including the clothes on their backs because the raft capsized again and again and again… the three men were rescued after 34 days at sea.
Learning to dance Ngabe-style
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“If we listened to our intellect we’d never have a love affair. We’d never have a friendship. We’d never go in business because we’d be cynical: “It’s gonna go wrong.” Or “She’s going to hurt me.” Or,” I’ve had a couple of bad love affairs, so therefore . . .”
Well, that’s nonsense. You’re going to miss life. You’ve got to jump off the cliff all the time and build your wings on the way down.”
–with thanks to Ray Bradbury for the words I wish I had written (everything in italics)
Fighting entropy
As a critical care doctor for over 30 years, my dad has seen many thousands of people die.
For the health worker this can be a vulnerable moment when the result was not what you wanted; you face your own mortality and your own ultimate powerlessness. I remember clearly the first patient of mine who passed away despite doing everything that could possibly be done. I remember feeling helpless and angry, at myself and at the world. And then I
The result isn’t always what you want
remembered something my dad said about patients and their lives and deaths.
My dad always says, when people die–sometimes it is a peaceful anticipated passing at the end of a long rich life, sometimes it is the unexpected nightmare of a child broken beyond repair by a chance fall–that no matter what we do as doctors, ultimately everyone gets the same: one lifetime; no more, no less.
My dad says that nowhere does it say for how long a life, only that you get ONE, and one only. In this job, you see how quickly it can be taken away; how sudden and how senseless. Arriving in a community in Petit-Goave, Haiti JUST in time to administer simple antibiotic eye drops to prevent permanent blindness in a baby with gonnorheal conjunctivitis…but also arriving in a community 2 days after a 22-year old Ngabe girl died of diarrhea that we could have prevented had we been there.
We are an impossibility in an impossible universe.”
One life…length indeterminate.
Struggling at the edge of the abyss
Why is it so hard to remember this every second of every day? Every breath is one less we will ever take; every step we take is one more both to our destiny and to the grave. So many external pressures can be brought to bear on us…money, peer pressure, social expectation; and so many internal pressures…fear, guilt, resentments. It seems like such a recipe for despair until we remember that ALL of us are Captains. Everything can be taken from us and a gun held to our heads, and even then we have the ultimate power not to give in, to retain that last bit of free will that is us, that chooses not to go quietly into the night but to rage against the dying of the light.
“So few want to be rebels anymore. And out of those few, most, like myself, scare easily.”
Returning from clinic, home in sight
We have that power; all of us know of ordinary men and women who were beaten and degraded into hell, and who somehow found that power within themselves to defy tyranny and refuse to be coerced. The martyr who suffers torture and death rather than renounce their beliefs…the concentration camp victims who chose a bullet and a communal grave rather than inform on their fellow prisoners…the young student in Tienanmen Square who stood firm before the tanks…the passengers on the hijacked plane who decided to go down standing up.
“Don’t ask for guarantees. And don’t look to be saved in any one thing, person, machine, or library.
Do your own bit of saving, and if you drown, at least die knowing you were heading for shore.”
You’re alive with the wind and the spray in your face
These ordinary people just like us became legend, but ALL of us have that power within us. Although very few of us have ever been put to the extremes above (and I hope I am never put to such an extreme test), all of us have faced moments in our lives when we had to draw on strength we didn’t know we had in order to survive–how to get past the loss of a child…the betrayal of your husband or wife of 40 years…all the way down to one day long ago when I was swimming far out at sea over deep water and got caught in a current. No matter how hard I swam, I was getting swept further out to sea and was getting more and more tired as the wind got stronger, pushing me away from the island. I actually don’t remember how I made it back to shore…I just remember making the decision right then and there that I was NOT going to die that day…and I swam. I remember breathing fire, choking on sea water, and not being able to feel my body anymore; diving down and swimming below the wind current, surfacing and being swept back, and diving again and again and again. My eyes were closed most of the time. To this day I have no idea how long that swim took…it felt like my entire life; my whole existence had been reduced to one great driving impulse…swim. And then I opened my eyes and saw the bottom sloping up below me and the breakers only a few hundred yards away…and then I was in the breakers, and as my body was hurled forward I went limp and the sea took pity on me and cast me up onto the beach, with nothing left. I lay there on the wet sand for a long time until I crawled above the tideline and lay down again. And that day I did NOT die. And I learned greater respect for the sea’s power and saw that for a moment I had touched within myself that spark of endurance that all of us have within us.
When those moments of extremity come we don’t always manage to access that power–what is is that stops us?? When the extreme tests come, however, there are always ordinary people just like you and me who time and again suddenly become strong like a wave harnessing the power of the whole sea and rise up to smash themselves against the rocks rather than retreat, “making nations quake, and monarchs tremble in their capital.” How amazing if we could unlock it at will to seize control of our destinies…to turn the power to defy a nation into the power to follow our dreams?
A momentary connection, once made, never unmade
How beautiful and how sad that a life with infinite potential richness should be such an eyeblink in the universe…each life unique and beautiful like a single wave among the billions of others rolling across the seas and onto the beach, only once, and then gone forever except in the echoes of what we have touched during our lives.
“Everyone must leave something behind when he dies, my grandfather said. A child or a book or a painting or a house or a wall built or a pair of shoes made. Or a garden planted. Something your hand touched some way so your soul has somewhere to go when you die, and when people look at that tree or that flower you planted, you’re there.
It doesn’t matter what you do, he said, so long as you change something from the way it was before you touched it into something that’s like you after you take your hands away. The difference between the man who just cuts lawns and a real gardener is in the touching, he said. The lawn-cutter might just as well not have been there at all; the gardener will be there a lifetime.”
One life…length indeterminate.
Make it count!
“Where would you like to go, what would you really like to do with your life?
See Istanbul, Port Said, Nairobi, Budapest. Write a book. Smoke too many cigarettes. Fall off a cliff but get caught in a tree halfway down. Get shot at a few times in a dark alley on a Morrocan midnight. Love a beautiful woman.”
Bring me that horizon…
