July 27, 2010.  San Pedro Sula, Isla Utila, and Isla Roatan.

I want to preface this blog by saying that the name ‘Floating Doctors’ WAS, in part, inspired by the Flying Doctors, a group of surgeons who started with one small plane flying down into Mexico to provide free care. When I last checked, they were doing thousands of cleft palate repairs, reconstructive surgeries and other procedures throughout Baja and the Sonoran Desert. When I was trying to think of a name that encapsulated my dream of doing something similar on the water, Floating Doctors seemed like a nice twist on a similar concept of delivering health care to remote locations. Why was I thinking of this particular piece of Floating Doctors history today? Well…

On Thursday we got the call from Aeromed; there had been a shooting on Roatan. A guy took three shots, one to the face, which blew off the end of his nose, one through the right arm and one chest shot on the right side–an entry wound but no exit. I don’t know why, and I don’t want to know. All I know is that 10 minutes later Sirin and I were at the airport with our gear and took the patient from the ambulance, loaded him and two family members onto the chopper, and took off for the hour-long flight to San Pedro Sula on mainland Honduras. It had been 16 hours since the shooting. The patient was getting very weak, lapsing in and out of consciousness and sliding down into deep shock.

As we climbed to 8,000 feet and the ambient oxygen levels fell, he got weaker and weaker. His blood pressure started to fall like a stone. In the shaking, vibrating helicopter I managed to get an 18-gauge IV line into him, and we pumped fluids in. He had a catheter in and his urine was dark yellow,and he wasn’t making much, so I was worried he was going into acute renal failure. His pressure came up with the fluids we put in, his kidneys kicked in, and he started making urine again. We kept the oxygen flowing, monitored his pressure and pupillary reflex, put blankets on him and raised his legs. We tried to will the helicopter to supersonic speed.

We landed in San Pedro Sula and transferred him to an ambulance that headed for Catarina Rivas Hospital with lights and sirens blazing. We breathed a deep sigh of relief and began cleaning the helicopter and arranging the gear onboard before retiring to a hotel for the night. In the morning, the helicopter took off to return to Roatan, but I requested they drop Sirin and me at Isla Utila, about 16 miles southwest of Roatan. We had gotten word that there was a 52 year-old patient there with terminal metastatic lung cancer and no relief for his suffering. The helicopter landed at the tiny Utila airfield. Sirin and I headed to Utila Lodge, which had agreed to host us for the night.

Our patient had worked as a boat captain for Kisty, the proprietor of Utila Lodge for about 25 years, and she was taking it very hard. Aeromed had arranged for a couple of available seats on a small bush plane from Roatan to Utila, so Martin and Annee flew in and joined us on Utila.

In Ireland, doing Care of the Elderly, I worked with the Palliative Care doctors often, trying to bring some dignity and comfort to peoples’ last days or hours. Many nights in Ireland I have spent a lonely vigil with the dying, monitoring their midazolam and buscopan drips, cranking up their oxygen and giving morphine to try and make sure they have as little pain and fear as possible as they make their last voyage in this world over the horizon and into regions beyond our reach. Our patient on Utila had lost 20 pounds in the last two weeks—he had actually been diagnosed way too late for any cure; his brain metastases had given him a huge seizure…and when they investigated, they found that he was riddled with cancer and probably had little time left. He had what I always think of as ‘that concentration camp look’…thin, wasted, and weak, with sunken eyes, his skull and bones on display under his parchment-like skin.

I was really happy that Annee, Sirin and Martin were there to participate and experience this particular consult. We visited our patient at his home and talked to him and his daughter for an hour or so. He was toughing out a lot of pain, just like a lot of my Irish patients used to do, but we could see he was very uncomfortable. He was also beginning to be a little confused, his appetite was non-existent. It hurt him to eat. He was sleeping very poorly. I wrote out a number of simple, easy-to-follow treatment regimes for him and left the medication with Kisty, who has an amazing clinical room at their dive lodge that was set up by her late husband. My gut feeling is that he is probably going to go to sleep sometime in the next couple of weeks and never wake up—at least I hope that is what happens. If he starts to deteriorate rapidly, we are on standby to fly back, and I will put him on a drip and do there what I have always done before— try to manage his fear and pain and let his last moments be at peace instead of in agony and terror.

The next morning, we hitched a ride back to Roatan on a catamaran that makes the passage between Roatan and Utila every day, then hitchhiked from West End in Roatan back to Barefoot Cay. I feel like a medical gypsy…with my plastic, not tin, coffee cup clipped to my medical bag ‘Have coffee mug, will travel!’ Suddenly finding ourselves on a helicopter over mainland Honduras, then on a remote little island doing a palliative care consult, then on a catamaran to Roatan, then in the back of a truck making our way home to the boat makes us feel like some kind of itinerant medical tinkers, stopping wherever there is need and helping however we can.

When the end comes for the gentleman on Utila, I don’t want it to be a violent passage through surf before sinking into the vast blue mystery beyond the reef that separates us all from eternity. For 25 years this Captain plied the waters here with pride and confidence, and I want him to be lifted gently by his last rising tide and floated out to sea with the dignity of a Viking on his last journey. This is the one voyage that all of us must make alone at the end, but I will do everything I can to help him prepare for the final passage into our memories. I and my fellow medical gypsies will be there to wave bon voyage, cast off the lines and tidy up the dock when he disappears forever over the horizon.

“Sunset and evening star,
And one clear call for me,
And may there be no moaning of the bar,
When I put out to sea.

But such a tide as moving seems asleep,
Too full for sound and foam,
When that which drew from out the boundless deep
Turns again home.

Twilight and evening bell,
And after that the dark!
And may there be no sadness of farewell,
When I embark;

For tho’ from out our borne of time and place
The flood may bear me far, I hope to see my
Pilot face to face
When I have crossed the bar.”
–Alfred Tennyson

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