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I distinctly remember the morning of my first mobile clinic with the Floating Doctors. Only knowing the small group of UCLA nursing and nurse practitioner students in my group, we were anxious and excited to get started on our first full day of volunteering. We quickly began shaking hands and making introductions unaware of the incredible experiences we would all share together over the following ten days.Within minutes I had met an orthopedic surgeon from Germany, a medical student from England, a nurse practitioner from Boston, and an emergency medicine physician from Australia (among many others). While from all over the world with widely different levels of experience and training, here we found ourselves together on an island in
Panama sharing the same goal to provide healthcare to those who would otherwise be without it.We all got to know each other quite quickly to say the least. Within minutes of meeting my fellow volunteers, we were pushing off, sitting shoulder to shoulder in a hollowed out tree trunk (literally) destined for Bocatorito, a small island about an hour away from FD’s headquarters. En route we shared stories of our past medical volunteering experiences and all agreed that even already we had never been a part of something like this.
Within a half hour of reaching our destination, I was immediately put into situations even five years of working in a busy trauma ICU in Los Angeles couldn’t have prepared me for. For example, after learning one of the women on a nearby island had just given birth, I experienced firsthand just how challenging it can be to count the pulse of a newborn infant with a wild parrot squawking away on your shoulder. Later on that same day we performed another house call, this time to a frail diabetic woman. We were able to deliver her much-needed medications, provide her with important education, and also leave her ten other family members with soap, toothbrushes, vitamins, and some toys for the kids. The smiles and waves we received from the children as we motored away from their dock is a mental image that I hope to never lose.
Over the next ten days, each experience proved to be something more unique than the day before. All throughout the trip our team of doctors, nurses, translators, and administrators worked, sometimes into the night, allowing us to see up to 140 children and adults in one day. Thanks to the diversity of the group of medical volunteers we were able to see patients of all ages and requiring all levels of care. The presence of our ultrasound technologist allowed us to perform pivotal pregnancy check ups, while our surgeon performed much needed wound closures. I was even able to use my intensive care background to assist when a decompensating patient arrived at our clinic hypotensive, tachycardic and in respiratory distress. After stabilizing her with IV fluids and performing a diagnostic ultrasound our team was able to safely transport her to the nearest hospital and receive further treatment.After days of traveling up and down the Panamanian coast, our trip began to come to a close. On one of our final nights in Panama the volunteers threw a “family dinner” at the Floating Doctor’s headquarters. After enjoying the food and conversation, I took a step back and looked over all of us who were complete strangers a week ago, now sharing laughs and stories like old friends. Looking back now, it’s easy to see how a group of dedicated volunteers, sharing a common goal to help others, could result in such a meaningful experience as the one I shared working with the Floating Doctors.
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MARCH 10TH: TRAVEL AND FIRST DAY IN BOCAS DEL TORO
The adventure began with a small group of eager travelers. We waited during these beginnings: waited for the train to take us into New York, waited to get out of the frigid cold airport, and waited to arrive at Panama. And after hours of travel, we arrived in paradise where we settled into our hotel and cooled off in the pool with some Latin tunes in the background. After an early start (3 am!), our group hopped on a plane to Bocas del Toro, where we were greeted by our sunny volunteer coordinator, Skye; the blue Caribbean sea; and the rooster outside our rooms.
After a much-needed nap, Dr. Ben, the founder of Floating Doctors, shared his vision with us on projects to better the community: like building walkways in La Solución, working with elderly people in El Asilo, and many more. We then met the team of devoted individuals who each shared Dr Ben’s commitment to better public health and access to medical care. And after our team meeting, we celebrated our beginning with hopes of making a positive contribution in the next few weeks.
Post by Carolyn
MONDAY, MARCH 11TH: FIRST WORKING DAY!
Bringing wood to the new walkway
Trash. A morning in the village of La Solucion definitely taught us to appreciate many of the basic services we take for granted in our everyday lives. Waking up mid-morning and heading out into the beaming sunlight, we “dove” into the waters below this makeshift community to clean up the trash that had been building up for months; we found the work to be both humbling and rewarding.
The casualties of Lucy, Caroline, Carolyn, and almost Patty by falling in the wastewater epitomized the fruitful sacrifices we made to help this struggling community. After a quick lunch of empanadas, served by the nicest and most caring Panamanian boy, we headed back out into La Solucion to tackle a bridge-building project and
continue with the garbage clean-up. This time however, our efforts were aided by children of the community (who by the way, were the most adorable and sweet kids ever). The smiles and cuteness of these children definitely alleviated our tired bodies and was definitely one of the major highlights of the day.BEACH. There is not a better way to rest from a day of hard labor than by heading to a nearby beach in the afternoon. Sweet waves and salty waters felt absolutely amazing. And after a picturesque dinner, where did we go? Back to the beach of course. A warm, loving night with the mellow sound of ocean waves crashing around us was the perfect way to end the night. La solucion? THE BEACH? Panama Spring Break 2013 couldn’t have started off on a better note!
Post by Jiou
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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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“Lifeboat Chronicles”
July 29, 2012
Blog by Las Tablas Peace Corps Volunteer Doug Martin
Sandwiched between the banana plantations and the mountains
Sometimes, early in the morning, the mist from overnight rain storms envelopes the town and hides her from outsiders. Sometimes the murky brown waters of the Sixaola River creep higher and higher until they stumble up and over the only road into and out of town. Its a place to get lost, a place to start over.
La empresa showed up one day, years back. They brought complex irrigation systems, John Deere tractors, and an airplane. The menacing drone of diesel fuel combusting hundreds of feet high shakes the town from her slumber. The cool evening breeze carried the seductive whisper of modernity; the people from the mountain came down.
For three days in July, sister Sky and brother Dr. Ben LaBrot and the volunteer group they head
A rare x-ray available…
offered free medical care to the communities of Las Tablas and Barranco Adentro. One can see in the hour long queues that the service their group Floating Doctors provides is desperately needed.
Their volunteer medical professionals work hard. Long days start when the rooster crows and often don’t end until after the sun has long settled behind the mountains. They sleep in hammocks strung up over cement walls, on sleeping pads strewn out over the floor, under mosquito nets. On Saturday the baseball game doesn’t end until two in the morning. Neither does the blaring reggaeton coming from the trunks of several baseball fanatics cars. But they never complain.
Hammocks hung in a half-built house…
Many people here do not have access to medical care. There exist several barriers – cost, culture, language – that have kept the people from the mountain out of a doctors office. The Floating Doctors work to remove these barriers, and not just by providing medical care free of cost. Dr. Ben is a leader by example, and his volunteers all show a genuine sensitivity and interest in the diverse culture of the indigenous groups that they attend. He also converses in Spanish after spending time in Honduras and Panama, and might accidentally greet you in the Creole French that he picked up in Haiti.
Dental Health is Important–send toothbrushes!
The end to each of their three multi day mobile health clinics has been bittersweet. Imagine being the captain of a sinking cruise ship with only one life boat. Mothers weeping to include their sons and daughters. Adult children pleading for their elderly parents. An uncomfortable undertone, asking “what more could we have done?” often lingers after the last patient has gone.
Somewhere beyond the mountains to the north there are children grown fat from too much and too many. Here the children’s bulging bellies speak not to a fast food diet and cable television but to malnutrition and constant parasites. What response quells the crying eyes of a six month old child, forgotten by the world and unable to access the most basic and fundamental care that he so desperately needs?
Fortunately, the Floating Doctors are continuing to grow. The most recent clinic expanded its offerings to both the thirty five hundred people living in Las Tablas and for the first time to another one thousand living in Barranco Adentro. The life raft is getting bigger, better stocked, and more efficient.
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Sometimes Conditions Are Against You
“Turning a ‘No’ Into a ‘Yes’–How To Adapt Your Mission For Success When Conditions Change”
Blog by Volunteer Doctor Jordan Amor-Robertson, MD (Pediatrics; Australia)
On my last weekend with the Floating Doctors a multiday clinic was scheduled in Bahia Azul (Bluefields), a Ngobe village which is on the mainland, however is only accessible by sea. We were fortunate enough to have some rather impressive friends (JP, a doctor, and Marie, a dietician) with a rather impressive boat called ‘Domino’ who invited us aboard for the journey. We even managed to fit in a spot of fishing along the way, reeling a couple of decent sized tuna, with the first fish-catcher (luckily not me) being required to eat the tuna’s still beating heart!
We had initially planned to run the weekend as a standard primary health clinic, as well as going house-to-house conducting a survey at the request of the community leaders to establish the degree of health knowledge with regards to HIV/AIDS, risk factors of the individuals and to perform clinical screening examinations for any features suspicious for AIDs. Unfortunately, shortly after our arrival, we received word that our application to practice medicine in Bocas had finally reached the national Ministry for Health and, whilst we had been granted approval to run clinics by both the local and state health ministries over a year earlier, we were advised that we were to suspend all clinical operations until such time as we managed to clear the required bureaucratic hurdles.
Now this posed a problem. The local Peace Corps Worker had invested a lot of time spreading the word to the community that we would be coming to do a clinic and laying the foundations for our HIV surveys. How could we now explain to people that yes, we had arrived in Bahia Azul, but actually no, we would not be doing a clinic. And, even worse, how could we possibly turn away the sick patients that would undoubtedly present for treatment? Do we turn-tail and commence the 4 hour boat ride back home straight away?
As it turned out, this was not the disaster it first appeared to be, but rather an opportunity in disguise. After a hurried brainstorming session, the decision was made to host a ‘charla’ or discussion and to share a lunch with the community. This would give us a rare opportunity to develop the Public Health aspect of our operations, something that is an important long-term focus for the Floating Doctors, however is often put aside somewhat during a multiday, in the face of a hectic clinical work-load.
Beautiful But So Far From Any Services…
We split into groups of 3 or 4, heading off in different directions in an attempt to reach as many families as possible to advise them of this unexpected change of plans (and to invite them to lunch!) A casual stroll through the jungle, thought I, on this glorious tropical day. Appointed our trusty guide, a young Ngobe boy who wants to be a teacher one day, Jenny, Lorie and I set off into the jungle, stopping at each dwelling along the way. We were welcomed into homes where we were given gifts of shells, bananas and guayaba and I even managed to fit in a little shopping along the way – in the form of a colourful traditional handwoven bag.
Unfortunately Lorie had difficulty negotiating the first major hurdle – a dauntingly steep and slippery hill – and parted ways with Jenny and I. I later learned that Lorie, in true Lorie fashion, had befriended the occupants of the house at the bottom of the hill (despite speaking minimal Spanish) and spent the morning engaging them in songs and colouring-in sessions.
Meanwhile, back on the jungle trail, Jenny and I were feeling increasingly like intrepid explorers, ducking under vines, clambering over rocks, leaping over puddles. And then it got real! Our guide ushered us into a kayuke (a traditional dug-out canoe), making sure that the inexperienced gringas were carefully balanced to avoid capsizing, and started paddling up through a mangrove river. We arrived at our…destination? A patch of muddy mangrove ground, indistinguishable from the other patches of muddy mangrove ground we had passed along the way. Apparently this was the only way to access the next lot of houses up on the hill that lead around the bay.
The Panga? Easy To Negotiate. Those Cayucos? Harder Than It Looks…
I stepped out of the kayuke tentatively, immediately realizing that my trusty Aussie thongs (or flip-flops as the rest of the world seems to call them) were grossly inadequate for this kind of terrain, losing both in the mud at the very first step. So shoes off it was, and I set off, barefoot, through the mangrove mud, as the crabs and miscellaneous other creep-crawlies scuttled out of the way. Now this is not the ideal way to greet strangers; barefoot, sweaty, mud up to the knees (and splattered even higher as a result of various misadventures), but still the matriarch of the next house greeted us warmly, offered us water to wash out feet and proudly showed us her garden.
And so this continued, from one house to the next, until it was time to return to the centre of the village for the Charla and the delicious lunch that the village women had prepared from our supplies. And, as exciting and memorable as the morning had been, this is the moment that all our efforts came together. After a brief introduction we opened the floor to the community, encouraging them to identify their key health concerns, common issues in the community and things that they would like to learn more about.
The session ran better than we could possibly have hoped! With a very good showing from the community (we filled a whole classroom and many more peered in through the windows), and an even representation of both men and women, everyone was granted the opportunity to have their say. Quickly the conversation turned to the topic of HIV, something that we knew the community were concerned about, however we were not sure whether they would be keen to talk about such sensitive matters in the public forum.
Much to our delight both men and women stood up and spoke openly and frankly on what they knew about HIV, giving us the opportunity to dispel a few myths and to outline the basic facts about disease transmission, progression, symptoms, treatment and, most importantly, prevention strategies. As one older Ngobe woman pointed out to me – topics of sex and sexual health were traditionally taboo, however now the discussions are too important to be avoided. For the sake of the health of her children she wanted to make sure they were educated on such matters so that they would know how to protect themselves.
Knowledge is the best preventive medicine!
Rather than being upset or annoyed that we were, on this occasion, unable to provide the primary health care services that are so needed, and so inaccessible to the people of Bahia Azul, they were excited to have the opportunity to discuss the key health concerns of the community, knowing that this would help the Floating Doctors and the local community to work together better in the future. That weekend was just the beginning – on subsequent visits to Bahia Azul the Floating Doctors intend to have ongoing conversations with the community about what they want and ongoing Public Health Education sessions. We are also hoping to do some capacity building with the local parteras (midwives) and other interested members of the community, many of whom have already nominated themselves as wanting to up-skill in basic health care so that they can act as Community Health Workers, allowing for a permanent health-care presence in the community.
That particular weekend was special, but it was in no way unique. During my time with the Floating Doctors there were countless occasions where we had the opportunity to engage with the local community, working with them and for them, to enact change and to begin establishing grass-roots health initiatives. I returned to my home in Australia revitalised and inspired, already planning my next stint in Panama with the Floating Doctors and the Ngobe communities of Bocas Del Toro.
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Blog by Volunteer Doctor Jesus Niebla, MD (United Kingdom)
Amputation in the field, at the top of a mountain…
I am a man who before this trip was scared (well I’d say apprehensive) of heights, mountain paths with sheer drops and free running river crossings.
I was not too fond of thunderstorms either.
In the early hours of the 16th of July I set off with the Floating Doctors on a surgical follow-up appointment. In the UK its normal for the patient to come to the hospital, wait an hour or so and get seen by the surgeon who operated on them, then go home. This appointment was different, we went to them, that’s the fundamental difference in our mission.
What a beautiful walk in good weather…
But when I say ‘We went to them,” what exactly do those few words mean? We took a high-speed water taxi from 25 miles from Bocas to Almirante on the mainland–it takes about 35 minutes bouncing and thudding through the sea. From Almirante we bundle our way into a taxi, pick up some supplies (water, tuna, rice, condensed milk, Gatorade and the important Panamanian Hot sauce). It takes about an hour to sliver up the shoulder of this mountain motor-way to our first base camp. The scenery is lush, I’m pretty tired from the early rise, but I stil take some time to enjoy it while my team-mates sleep (a wise choice with what was ahead of us).
Eventually we get to our base camp, Pueblo Nuevo. It’s the rendez-vous with our guides and pack horses. We charge up on some rice, chicken and the tastiest avocado I’ve set my hands on. We meet our guides and horses to help take the heavier loads; they ride ahead. The horses effortlessly cut through the path ahead–they go first as they scare any snakes or nasty surprises away. They pick their way up the steep climbs with practiced ease; its what they do almost every day and they know the way better than we do. We find ourselves walking on a parallel and tricky path, crossing an Indiana Jones style bridge (except we’re not surrounded by bad guys and its in fairly good shape, although the odd broken panel wasn’t too reassuring).
We make our ascent, climbing up and walking down the steep- clay-brown-well beaten tracks, but this didn’t make them easier. Our guides soared up the tracks with embarrassing casualness.
6 Nationalities Represented in the La Sabana team…
In-between the sweat, heat, humidity, knee-deep mud baths, sheer drops and snake shaped branches there was a different assault of the senses, a real appreciation of the beauty of this place. Our path dissected fields through flowing rivers, to the butterflies that garnished the clear, blue-sapphire sky above us. It felt like scenery that was the mostly an inspiration of the Steven Spielberg classic Jurassic Park. At every bend in the trail I expected to see a Tyrannosaurus.
Four hours later, sore legs and sweat soaked we make our 2nd base camp of the trip. La Savana, “The Grasslands” and such an aptly named place. We try and rehydrate and rest, an hour or so passes, and too soon it’s time to find and see our patient. We head off again, although this time only for an hour; I’m relieved at this small amount of time, but the path is much different. It was such a steep incline compared to the other paths. Perhaps it was the cumulative effect of the trip, the dehydration, missing the most important meal of the day (breakfast; I know, schoolboy error), but I think I must have hit the wall as soon as I reached the house where our patient lived. Luckily Ben had a Gatorade, it made such a difference.
Toe Amputation 1 Day Post-Op
This didn’t matter, the fact our patient was pretty much running down the hillside to meet us. His actions and motion answered so many of our questions effortlessly. He was fine, he pulled off his wellington, the amputated toe we came to see had healed nicely. There were no signs of infections and the skin flaps were opposed nicely. There were no problems with his balance or ability to continue with his daily routine, although I expect he is a bit more cautious with his machete.
So we made our way back down to Las Savana, make a few house calls on the way (including ANOTHER machete wound), see some patients with pulmonary TB (surprisingly a clear chest on auscultation). We bump into some National Health workers and have positive interactions regarding sharing the responsibility for the medical treatment of the patients with TB.
Eventually we settle back to our camp, have an impromptu clinic under the village’s rancho and soon meet a 6 year old boy with a tricky problem. His father mentions he has a piece of maize in his ear. Ben attempts to extract it, but we just didn’t have small enough tools (my first Job is ENT; I’ll see if I can borrow a set next time). One part of Floating Doctors’ mission is to bring healthcare to patients, if this can’t be done we bring the patient to healthcare. That is exactly what we decided to do–help with the transfer of this young patient and his father to the local hospital. This would normally mean a good 4 hour walk, a few bus trips and perhaps a taxi, so we would accompany them and cover the cost of travel and any medical fees.
The next morning we set off down the mountain with the corn-in-the-ear boy and his father, thinking that descending it would be a little easier. The horses have the heavy loads and we are pretty much on a continuous descent. We still cross the same rivers, and there a few steep sections, but the sun is a lot kinder than on the way up.
Incredible patient bravery
A few hours into our walk back it starts to rain, at first a welcome change. We progress, but the rain doesn’t stop–instead it intensifies; the heavens have opened above us. It doesn’t take long for the well-trodden path to become a quagmire. Now it’s a like playing hotch-scotch, planting one’s feet on anything that isn’t the centre of the path otherwise you’re the stick in the mud–a knee-deep mud bath. The downpour also makes the river crossings a tad trickier, as the water level rose significantly in less than 20 minutes.
I am all up for a bit of a challenge, the mud isn’t too bad, we all get used to it, but it saps one’s energy. There is the odd fall, but nothing too serious to anything other than pride. The quagmire now turns into small rivers of chocolate-milk-mud, and then the heavens open a little bit more and decided to spice things up. A thunderstorm starts, we are about 1-2 miles from Pueblo Nuevo, and the more we walk through the jungle trenches the smaller the gap between seeing the lightning above and around us in the canopy and the sound of thunder. We are walking into the eye of the storm. The pace and urgency naturally pick ups, each snap of thunder signals a small sprint for me, then a lull, a sense of dread and then back to a fast march.
An opening is ahead of us, not only are we void of the “protective” jungle canopy but we have to ascendand cross a high, open hill. I recall saying to Ben and Steve we have to clear this ASAP. All the pain, muscle ache and fatigue from the last and current day of trekking for miles of tricky terrain and river crossing all disappeared, the adrenaline was released with a mighty crash of thunder directly above us and and fight-or-flight chemicals coursed through my arteries and veins…. I sprinted up the hill, I slipped on the muddy slope, I got up. I am on my hands and knees trying to get up this hillside as quickly as possible. The desire to get over this death-trap is like nothing I have experienced before. I crest the hill and slide down on my backside, it looked inviting but a few stones and rocks proved otherwise on the way down.
We start work pretty much on awakening…patients waiting…
Only a small stretch of jungle is left, and at last we step onto a concrete path that signals our re-entry into Pueblo Nuevo. Stumbling our way through the village back to the shop where we had eaten before making our ascent on the mountain path. To my amazement the town is bustling with Ngabe who have come down from the mountains to place their vote in the general elections, tightly packed under the tin roofs of the local school to shelter from the storm. It gets more ridiculous–there is a local football match ( Soccer) in the football pitch, at the centre of the school. I make a comment to Steve ‘How could the officials allow this match to be played, the pitch is waterlogged”, the players showed no concern of playing in the middle of a lightning storm…until a lightning bolt hits the ground 30 yards from them…then they scarper like they should have 90 minutes before.
We take a short break from the downpour, under the overhanging roof of a house, and the pain starts to re-defuse through my feet and is interrupted only by the thunder and crash of another lightening strike; this one shrieks and booms onto someone’s roof near by. Unfortunately this is followed by cries and panic. The message got passed through the crowed…shouting that someone had been struck by the lightning.
I turn to Ben; “Let’s go check it out”. We now make our way to two houses about 50 yards apart. These houses are elevated about 2 meters off the ground on wooden stilts. Underneath we meet a ring of 200+ people crowding around an 18 year-old Ngabe woman, crying and in obvious distress. Ben checks her out and she seems ok, just in shock (literally) and hyperventilating with some muscle spasms and pain. As we calm her we here cries of two more lightning-struck victims.
I sprint over to the other house (trying to avoid being hit by the continuous lightning attacks), but she is in another house–apparently they were inside when they got struck through the thatched roof. The crowd surround my patient; they eclipse my light; I can’t see. A few choice words and they let the light in.
I notice that her abdomen is distended. This lady is pregnant, 8 months pregnant. My adrenal glands squeeze their last drop of adrenaline. The baby!
She isn’t saying much; visibly shocked, dazed. So I’m thinking to myself, what do I do, its time to get this woman assessed as best we can and transport to hospital. ABCDE, it all comes back. Her airway is good, she is breathing, her lungs are clear, equal air entry. She is pulse is slightly elevated, with a normal character and volume. Heart sounds are normal. She seems a bit dazed, but is responsive. Phew! I notice she has a zig-zag burn starting on her right scapular, working it way down her back to about L5. Presumably the energy dissipated through her feet as she was complaining of severe tenderness in her ankles.
Amputation in the field, at the top of a mountain…
The third patient was a man who had been struck and hurled ten feet across the grass, and wasn’t able to move his arm. I was worried about compartment syndrome, another condition requiring a speedy intervention.
We needed to get the patients transported to hospital as soon as possible for a full review and appropriate investigations, in particular an ultrasound of the 8-month pregnancy. Practically this would mean hailing down a taxi on the jungle highway, or maybe a bus. Fortunately for everyone, this challenge was made much easier as we met some police officers who were able to drive us in a safe and speedy manner to the nearest Hospital in Rambala, a town some miles down the road from Pueblo Nuevo.
How the story ended…
The little boy with a piece of corn in his ear was admitted and had it removed under a general anaesthetic.
The two sisters who had been struck by lightning were both ok and thankfully so was the baby (although perhaps it will be born with super powers).
The man did not have compartment syndrome and eventually regained arm function.
Soaking wet, tired, feet-blistered, hungry and drained we sat outside the hospital and I realized this is what it takes to provide healthcare to these remote communities. On the long taxi ride back (in clear weather at last), and on the water-taxi back to Bocas in the deepening evening, the fear is now replaced with the drive to help these communities further. After a couple of hours of travelling we arrive back in Bocas del Toro absolutely devastated with exhaustion and satisfaction…and I realize this is just another day for the Floating Doctors.
I’m coming back.
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Today’s blog was written by one of our recent volunteers, Dr. Ravi Chokshi, just beginning a residency in Obstetrics and Gynecology. These are his thoughts and impressions of our 4-day mobile clinic up in the mountains to a remote village called La Sabana, or ‘The Grasslands.” Over 200 patients were seen, including pediatric and trauma emergencies. Thanks Ravi! best of luck in your residency, and I look forward to working with you again.
Field Amputation of Small Toe With Digital Nerve Block
He was different at first glance. Quieter. Saw more, spoke little and took his time to smile.
“It hurts here” he exclaimed pointing at his 12 year old heart.
I had examined 20 chests that day, listened to 20 hearts. But only his jumped at me as I lifted his shirt.
A heart that had decided the only way to get noticed was to become outgoing. I place my stethoscope and still the squall fighting within. My ears record and my fingers feel for the familiar radial pulse. There is a flaw here. A Woosh-woosh where a lub-dub should be. I bring over some counsel and we use the portable ultrasound to perform a tropical echocardiogram. What I had heard, we now see. A hole connecting the two atrial chambers of his heart, and a chance to be normal forever taken away.
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By the second morning, we had hit our stride. Awake at 7am with the hum of the village around us. I wish that I could say that I
Morning...Now Get Up And Convert The 'Bedroom' Into A Clinic! Patients Are Here!
slept wonderfully on the hammock. Tied across the wooden beams of the village Rancho, covered in a mosquito net donated by the Lake County Sheriff Cliff Matthews.
I almost did, but the cold from the two rivers that flow around La Sabana got to me.
To build your own bed where the clinic just was. Settle into it with the laughter of new friends around and your mind alive with the memories of the day before you. Of the cold stream water you had bathed in, or the hojaldras and coffee that had started your day. Sleep comes easy and you drift imperceptibly towards it as the days’ labor catches up to you and the hungry river swims around you.
The cold shudders in, and you wake up surrounded by the chatter of excited Ngobe children. A quick breakfast and swim later you are ready for work. Walking back from the river you can already see a mass of patients organizing themselves around the rancho. In 10 minutes a fully functional clinic sits where we had just dismantled our bedroom. A pharmacy lies ready and capable. Our amazing interpreters have already lined up patients, sequestered the roving bands of excited children and started patient intake. I sit with my stethoscope around my neck, a clipboard on my school desk of a chair and try to look ready.
Filling Up Fast As Word Gets Around...
This is impossible.
And we begin! In groups of 4 to 6 the mothers and fathers patiently answer my questions posed in broken Spanish while the kids run around, openly gawking at me and my strange tools. As I address them, smiles break out. They are terribly shy and hide their little faces in their mother’s dresses. But I bring them out and I let them listen to their heart beat through my stethoscope and I see their eyes widen and them calling out their amigos to do the same. ‘Ahh this crazy gringo is funny’.
I hear about coughs and colds, about chronic pain, about diarrhea that just won’t go away. I examine distended bellies and the scars from years of no-see-um bites and battery acid burns from cured cutaneous leishmaniasis. Most of all I see the relief as I dispense Albendazole like candy telling them, “Este Medicamento va a quitar las lombrices de su estomago y su piel”. And I urge them to eat it in front of me. I work in a chain with 4 other doctors, most with many more years of experience than me and I confer with them constantly. I learn to recognize scabies and lice and infected wounds and what treatments we can offer for such. I get called occasionally for my input on obstetric patients, being that it is my area of interest.
Using the Sonosite I am able to show a woman 7 months pregnant her unborn child’s face and lips and nose. The kick she feels – she now sees and she can’t stop smiling. In a place where most of the people have never seen an outsider, a white person, or even a TV an ultrasound is magic and we are a mystery they are too polite to solve.
We are observed constantly. And for good reason. In a place as isolated as this from the rest of the world, we are as alien to them as
Most People Living Here Have Never Been More Than 10 Miles From Home
imaginable. Taking a picture of the children and showing it fascinates them. Then I realize why. There are no mirrors here, no still water. Their first good look at themselves is thru the lens of my camera.
These are the Ngöbe-Buglé Indians, Panama’s largest indigenous group. After years of historical fighting they were allowed to retain their ancestral lands largely confined to the western rainforests of Panama. Here in their Comarca, they implement their own system of governance and economy. In terms of healthcare they have a raw deal. A long history of poor interactions with outside groups (pretty much everyone since the first explorers) has left the Ngöbe understandably skeptical of ‘Meriginees’ (non-Ngabe people). As the mother of a very sick Ngöbe child put it to us, “the hospital is where we go to die.” Language is another barrier. While the Ngöbe men have reason to conduct business with communities in close contact with the mainland and thus have some Spanish speaking skills, the women and children are different matters. Not being able to speak Spanish in Panama is as isolating as it gets.
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Day 1
La Sabaña, the remote Ngobe village that we have made our way too, is one of the more isolated communities dotting the Chiriqui
Don't Let It Get Above Your Boot Tops! Too Late!!
province of Panama.
Our journey there begins at 5am from Bocas marina, where the Southern Wind currently rests.
A group of 9 odd, we sleepily catch a water taxi to our first destination – the port town of Almirante. Blazing through the Caribbean on a 200 horsepower boat is enough to get everyone up and awake.
?Costa Rica!, usted? is the banner cry as we disembark.
Ahh Almirante. A hastily thatched together port town created entirely by the Chiquita Banana Company, it is best described as a jump off point to better places.
Brushing off the taxi drivers, we find ourselves in a car on a 90-minute ride to the sleepy little village of Pueblo-Nuevo. A tasty Panamian breakfast of fried bread and coffee awaits us and now we are ready for our hike. Ben has hired horses to carry the supplies up the slope, while we carry only water and essentials on ourselves. A 3-hour hike when dry, 5 plus when wet and we approach La Sabaña by late afternoon.
La Sabaña – literally translating to ‘The Grasslands’ is a mesmerizing place. Found at the crossing of two rivers, its thatched huts and raised wooden floors are as living artifacts to the age before Panama won the geographical lottery and started collecting revenue from the canal. The Ngobe here live simple lives, the men work in agriculture and raise animals. The women take care of the children and keep the house, all while dressed in the colorful patterns unique to their culture.
It is here we are most in need.
Day 2:
Along with the storm, comes the call from up the mountain. A child has been hurt severely, on his foot by a self-inflicted machete cut. Ben quickly
The Second Toe Can Be Saved; The Small Toe Has To Come Off...
dispenses half our group with the general surgeon on a race up the slope. I am part of the group that stays behind, together seeing the last few families waiting to be seen. The number of patients has been growing larger every day. Word has gotten around about us and families have traveled on foot for many hours to see a doctor, possibly for the first time in their lives. I have to remind myself of this, as I quietly ache to learn what is transpiring with our other half.
Hours we wait, the rain pouring down, the darkness absolute. The conversation feels forced, every one’s mind on our missing party and what has transpired with them.
Moments before a search party must be raised, their lights are spotted, little moonbeams making their way down the muddy path. They have returned, soaked to the bone but with stories to tell.
It had been necessary to amputate the 10 year old child’s little toe. Amputate it. In the darkness, working on a wooden floor guided by headlamps.
They had quelled the bleeding, stitched it together and addressed his pain as best as they could. We would return the next day with antibiotics and supplies to redress the wound. To leave supplies and to teach the family to keep the site clean. And a phone number to call, just in case.
Day 4:
He Deserves Access To A Doctor If He Gets Sick!
By our last night the hammocks come up like clockwork. Clinic today had been a sold out success. Patients came from all around the mountain, with many families walking a day’s journey to reach us. We had worked like a well-oiled machine.
As we pack our boxes for the long journey back, the stories come through.
And its not the number of patients seen that we count, but the tooth brushes we had run out of. The soap we had no more off. The medicine for scabies we had to deny.
If there were patients to count, they were the ones we now had the responsibility of following up on. The 12 year old that needed to see a pediatric cardiologist. The women with suspicious breast lumps that needed mammograms, and the ones we couldn’t quite put a diagnosis on out in the field.
Ben and his crew will arrange transport, appointments with the necessary consultants and provide a voice of advocacy to accompany these patients.
What I have seen here erased all presumptions I had before the trip. We were there to see patients and dispense medicine yes, but much more importantly we were there to build trust. To raise the community up bit by bit. To give out toothbrushes and teach kids how to clean their teeth. To teach mothers to recognize dehydration in their children and how to make ORS. Most of all, to provide the village with an avenue of communication they could rely on when posed with a serious problem.
I had been promised an experience of a lifetime when I signed up to volunteer. I say they undersold it.
Our Patients And Friends From La Sabana
Four days I lived alongside the Ngöbe Indians. Absolute cutout from the world I knew and an absolute outsider to this hidden world that time had forgotten. I almost died. I very nearly lived. I fell in love again. I yearned to go on, to live this fantasy of waking up in a hammock with lines of patients to see and a fast flowing river to bathe in. Four days is much too short but somehow felt like a lifetime in terms of lessons learned.
In a few short weeks I will return to the US to train in one of the most developed and technologically advanced healthcare systems in the world. I will learns volumes everyday and gain skill sets I ache to possess. But it will always be in a remote Ngöbe village in the protected area of western Panama where I first really learned the gravity of the promise we make everyday on saying these words, “Me llamo Ravi. Soy su Doctor”.
Added by Ben La Brot:
“It is from the numberless diverse acts of courage and belief that human history is shaped. Each time a man stands up for an ideal or acts to improve the lot of others or strikes out against injustice, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring, those ripples build a current that can sweep down the mightiest walls of oppression and resistance.”
–Robert F. Kennedy speech in South Africa, carved in stone on his grave.
"Me llamo Ravi. Soy su doctor."
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maggots in a tunneling ulcer
Ah, the Asilo…one of the places we heard about here in Panama when we were still in Honduras. We found a unit seldom visited by a doctor (in a year), but with a wonderful staff of no more than a cook, cleaner and nurse on each of the two 8 hour day shifts and 2 on the night shift. There are 27 patients there, all elderly, ranging from totally mobile to totally bedridden, some without sight, some without limbs, many with varying degrees of dementia—they all have to be fed, bathed, many changed, floors cleaned, meals prepared and cleaned up after…the fact that the floors are clean and the patients are clean and fed is an extraordinairy achievement, but the patients need more attention.
When we got there I thought they were totally medicated…so many of them looked so catatonic…it turned out almost none of them were medicated,
They seemed so catatonic when we first were working there
or where very occaisionally medicated. They were just bored and unstimulated, almost into catatonia. It was months before some of them spoke; I came back from 5 weeks in California to find patients that I thought had no power of speech actually talking with me. It was like awakenings, and it isn’t because of medication, it is because of all the time our volunteers and people in the community have spent with the patients there. Many had not been out of the grounds for years, and now walk in town weekly—our friend Javier, a Colombian physiotherapist in town who also works at the Asilo, brought his four horses and our elderly patients dressed up and rode like kings and queens through the streets, looking down around them as if to say ‘So…this is Bocas, you say.’
one of 3 trucks of trash we removed
The mayor sent three trucks and we removed several tons of rusted metal and trash from the grounds and landscaped a little (more to go), repaired two broken washing machines and plumbed 3 in total (the only working one had been filled by bucket), installed handrails in the common area for walking and physio, changed the showerheads to removable handle versions, put a commode chair in the bathroom, created and update charts for the patients, provide medications, and have done our best to provide the additional more advanced care that the staff are sometimes not able to provide.
When we arrived, there was an elderly stroke victim, immobile and unable to communicate, and terribly emaciated and contracted with bedsores
emaciated, rigid, and covered in bedsores
all over. We worked for weeks, doing wound care and working with the staff to use advanced wound dressings we provided and creating turning regimens—our goal not to extend his life, but to allow him to die with more dignity and in greater comfort. At one point he got a chest infection and we stood by to administer oxygen and midazolam and buscopan to make him comfortable as he passed, but he rallied…and subsequently gained 12 pounds and the ability to focus and speak a little (very, very little) before he died quietly one night in his sleep a few months later.
ulcers spreading in a deteriorating body
And he died with not a single bedsore on him…that was a victory to me, at a personal level. I hate it when people die with their bodies disintegrating externally around them as well as internally. It is unnecessary, but totally natural for birth and death to be so awkward and difficult…the first time doing ANYTHING is usually awkward and difficult: the first day of school, first kiss, first great loss, first great love, first great adventure, the first and final sunset cruise, and finally, the end of the voyage.
Any ship, no matter what storms it has weathered and what damage it has sustained in a long life of navigating unknown waters, wants to look its best when it pulls into harbor for the last time. There should be dignity at the end, as much as can be wrenched from an unfeeling universe. Not always possible…but always a betrayal not to even try.
My cousin, a physical trainer, just arrived here for a few months…I have another patient in the Asilo who has not walked for 9 years after his stroke. He stood up the other day after exercising on his own, ferociously, with some basic exercises we showed him after we applied a difene patch to his paralyzed knee for knee pain, and he and we found out the immobility was more pain-related and he could move it a little. He freaked out an dhas been exercising like a fiend.
Our friend Bolivar snapped some pics in the asilo while we were working there one day
I came back from California and he collared me from his wheelchair and looked me in the eye and said ‘Yo Puede CAMINAR!’ And stood up, giggling like schoolgirl. Sometimes things are too much for me to process when they happen…later at night, especially when I’m writing a blog or making a facebook album of the day, I start to process…thinking about that patient a lot. I want to go for a walk with him before he dies—and he might live for many more years, so if he does, I’d like him to be able to walk, and he REALLY wants it, more than almost any patient I’ve ever seen. I feel tiny beside the strength of his determination.
Matt and I changing a suprapubic catheter blocked after 11 months of neglect
I tell all my incoming student volunteers (I have my little speech about this prepared): “You are so lucky we have the Asilo for you to volunteer in. Not only does every second you spend there interacting with some of the loneliest people I have ever seen benefit them beyond what you can know, but care of the elderly—and especially in this setting—is where you find out if health care is for you.
Eve and Sarah doing wound care on tunneling ulcers
“Yes, it’s challenging, the medical issues are very complicated, the patients may have dementia and can be challenging, and you have few resources to deploy except what you can somehow manifest…but beyond that, its where you learn things like ‘are you the type of person who is thoughtful enough to throw a corner of a sheet at least over the exposed genitalia of some bedridden shell of a human during some procedure that leaves them all exposed?’ Or ‘When you lift a frail contracted foot off the bed, do you automatically support the knee out of awareness (to avoid torqueing the knee)?’
walking the patients
“It’s a good place to learn PATIENT CARE…not something everyone can learn, because some aspects of it I just don’t think you can teach. I feel like I have to practice at it constantly…people are afraid of old people…can you learn to look past the rotting shell of their failing minds and bodies to ressurect in your mind’s eye when you look at them the glory of their individual histories? It is like looking at old ships tied up in the scrapyard and neglected, never to leave again…remember that those ships voyaged 70 or 80 years across 2 or 3 of your lifetimes…can you see who they were and what oceans and storms they have passed, somewhere inside the wrinkled, frail bodies awaiting their final voyage?”
I love the Asilo…my volunteers go more frequently than I (I only have 2 hands) these days, but I love going in and seeing my friends there. We need people in the community to each give 30 minutes once or twice a month…come on…an hour a month, that’s pretty good…want to walk patients with us? It is awesome—email us or (better) contact us on facebook if you want to go for a walk with us and be checked out to walk patients on your own. One hour per month…you saw the walkway we all built in La Solucion; a miracle happened because everyone showed up and made it with their hands and time.
giving time
Make a miracle happen at the Asilo…everybody give an hour a month, and every patient will be walked several times a week instead of never. They’ll get stronger and be more fit (less pain), and be more mobile (and they HAVE to be, the ones that are bedridden have the worst time of it). Let’s make it happen Bocas!
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I need an opthamologist
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
I love my sister
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.
Canadian medical student doing kids health checks
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…
ultrasounding in a chair in the jungle
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;
Harold, Peace Corps worker in Shark Hole; we did a clinic there on his very last day on site...a giant amongst his Ngobe friends; thank you Harold for your fantastic work
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…
