By Katherine LeTendresse, Student at Global Medicine Program, USC 

Floating Doctors Volunteer

My first toothbrush!

From the first hours encountering the health professionals who volunteer with or work full time at Floating Doctors, I had the feeling that the week ahead of me would be filled with interesting cases to learn from. What I realize now is that the cases, no matter if they were routine or unique, have filled me with a renewed sense of compassion and helped me apply the concepts that I have learned this year as a student in the Global Medicine Program at USC.

The country of Panama is a culturally vibrant place in Latin America and like many of its neighbors faces challenges with healthcare infrastructure. Though it is considered an upper-middle income country by the WHO, many of its citizens struggle with healthcare access, often due to poverty. The areas in which indigenous peoples live are often isolated rural villages, further complicating the process of accessing health services, many of which they struggle to afford. One large challenge regarding healthcare in Panama is that it must address the double burden of infectious diseases, such as Malaria, Leishmaniasis, and the Zika virus, as well as non-communicable diseases such as Obesity and Cardiovascular Disease.  In addition to these challenges there are a lack of services and education in my area of interest, oral health.

Like many other countries in the region, the children I saw in Panama had access to food and drink high in sugar, such as soda and candy.

Clipping toenails and providing much-needed care and attention

Rural populations in Latin American countries are typically thought to adhere to traditional diets high in fruit, grains, and vegetables, whereas the diets of urban populations have shifted toward Western staples. This can contribute to an array of health issues including obesity and oral health problems. The imbalance between energy expended and caloric intake is a challenge that is expanding into rural areas, which I observed in Bocas del Toro. At the end of one clinic day in an area called Quesbada Sal, I walked passed cases of soda being unloaded from small wooden boats onto the dock. This island is an hour away from the main town, and is an example of how diets high in sugar are penetrating rural environments.

The level of sugar intake, along with the use of water untreated with fluoride, was reflected in the oral health issues patients presented with at the clinic. Only a handful of children were living completely free of dental caries, and many more were living with rampant tooth decay. I had never observed such a high number of extractions of the deciduous teeth, prompted by severe tooth decay, reducing a once healthy tooth to one causing constant pain. Other children with less decay received fillings, which were performed using only basic instruments, no drill or suction. The atmosphere of the dental side of clinic was one where we did the best we could with what we had. One extraction was even done without a dental chair, on the steps of the clinic. What I admired most about the dentists as well as my peers was their willingness to improvise and to provide the best care given the circumstances. The overall community response to our presence was largely positive, with many patients waiting hours in the queue to be seen by the dentists.

Well baby checks are one of our favorite consults

One thing that struck me immediately at these rural clinics was the number of locals who had never been seen by a dentist before.  Many of these people were of the indigenous Ngobe population, and though I expected them to be hesitant of us they surprised me with their welcoming attitude. Some of the patients we saw were children at their first dental visit, but others were adults who were having their first experience as well. The reputation of Floating Doctors within these communities was a great asset, and without the trust of the community these patients may never have come out to be seen.

What was most challenging was the management of patient anxiety, especially in our pediatric patients. While I assisted the two dentists, Sarah and Philippe, I observed them using an interesting technique to calm a patient, a scared three-year-old girl. The conventional method of managing anxiety in pediatric dental patients, called “Tell-Show-Do”, was not successful with this child, so they decided to try a different method. The mother sat on the chair and held her daughter on her lap, and this calmed the girl enough so that Sarah could perform the dental exam. Over the course of this encounter the patient began to relax, and she received a filling for a cavity on one of her maxillary teeth. It was interesting to see an alternative to the usual methods of managing patient anxiety, and to gain perspective on situations where a practitioner must adjust their plans in order to be effective. Though it was challenging to calm this young patient, it is my hope that this introduction to dentistry was positive overall, and that she will be responsive to oral health education in the future.

Though we were busy with the high volume of patients, we still took the time to hand out toothbrushes, toothpaste, and speak with the children about oral hygiene. My group created a poster that taught the techniques of brushing and flossing, which was both informative and colorful. This was one of my favorite activities while working in these communities because education is essential to changing behavior and effecting long-term health. The people in these communities were receptive to new information, the children most of all. After being taught about brushing their teeth they seemed to share what they had learned with their family and friends. The children would line up and ask for “cepillos” and “colgata”, which I quickly learned are their words for toothbrushes and toothpaste. The children seemed genuinely curious about the dental station, and on several occasions I saw their intent faces peering in at us, and I felt as fascinated by them as they were about our work.

Consulting with the whole family together

In the short-term it is a small victory to teach a child to brush their teeth and give them the means to do so, but the real challenge ahead is to address how they will maintain these health behaviors. Will they have access to basic supplies like toothbrushes, toothpaste, and floss? If not, how can this be addressed? This is something that has been in my thoughts since returning from Panama, and I realize that solutions will ultimately have to be a result of prioritization within the communities. There must also be a strong presence of healthcare providers to stress the importance of maintaining these behaviors. This is one of the many reasons that Floating Doctors is important for the area, and why the Global Medicine Program should continue sending students to participate in this valuable experience.

Another portion of the trip that will likely have a lasting impact on my perspective of the world was visiting the local nursing home on the main island. From the moment I walked into the facility I had to challenge my expectations and reevaluate my assumptions about the culture. I met several residents who had been abandoned by their families, and others who lived there with family members. One example of this is a woman I met who lives in this facility with her mother as well as her sister. They are only in their 40s, which by US standards is a young age to be admitted to a facility for long term care, with 88% of residents being age 65 or older. However, both appeared to have mental health issues, and with nowhere else to go they were admitted to the nursing facility.

Until you have no one to talk to, you might not realize how important that is!

Spending time with these women made me reflect upon the idea of treating every person kindly and helping them live with dignity. As I stood in that room where upwards of fifteen women slept, my only desire was to give them attention, show compassion, and let them know that someone cares. I could sense this motivation in all of the volunteers there, saw it in their body language, and heard it in the kind words they spoke. This experience was one of the most humbling I have had in my life because these residents value the things we often take for granted, like a conversation or a hand to hold.

After spending time with the residents of the nursing home I have reflected on my career and am drawn to the idea of practicing as a general dentist where I can see children, the elderly, and everyone in-between. Moreover, it renews my sense of purpose for seeking out education as dentist, and where I may practice in the future.

Easy cross-cultural trust is a wonderful thing to see

Though we were only in Panama for a short time, the long-term impact of our visit can come in the form of support for Floating Doctors and other groups like it. Beyond giving care that is needed, Floating Doctors educates their patients at every opportunity. What has stuck with me from this experience is that while we address issues such as access to healthcare and overall health we should also empower these populations with knowledge. Perhaps one of the children I spoke to about oral hygiene will someday become a dentist, a physician, or an advocate in their community healthy living. Educating is the key to empowering all people, and it is my hope that the people of the Ngobe communities will be positively affected in their health today and in the future by continued efforts from Floating Doctors.

References:

1. WHO Panama Profile Socioeconomic. World Health Organization. 2011 Report.
2. Panama – Health in the Americas 2007 – Volume II. Pan American Health
3. <paho.org>.                
4. Kain, Juliana et al. “Obesity Trends and Determinant Factors in Latin America”. Cad. Saude Publica, Rio de Janeior, 19 (Sup. 1): S77-S86, 2003.
5. Farhat-McHayleh N. Harfouche A. Souaid P. “Techniques for Managing Behavior in Pediatric Dentistry: Comparative Study of Live Modeling And Tell-Show-Do based on Children’s Heart Rates During Treatment”. Journal of Canadian Dental Association. May 2009.
6. Nursing Homes Fact Sheet. AARP Public Policy Institute. Oct. 2007.

By Dr. Kevin Lan

Lead Dental Provider

Floating Doctors

A new year upon us, and what a year 2015 was for the Floating Doctors. I would like to update everyone with the progress our dental program has made and share a few stories of the past year. Our work and development would not have been possible without your support and kind donations, I would personally like to especially thank Don Scott and Ted Hannig for their tireless efforts in raising over $10,000 to help with the advancement of our program in acquiring essential equipment and materials.

At the close of 2015, we have extracted over 300 teeth, placed more than 100 fillings and incised and drained multiple abscesses. We are now able to provide a wider range of treatments with our newly acquired portable dental chair and equipment from Dentaid and Aseptico, as well as receiving several thousand toothbrushes from Global Grins and supplies and tools from Henry Schein.

It was fitting that our last dental clinic of 2015 would finish in the community of Norteño, where our program first started. 70 patients were seen over two days working from the early hours of sunrise until the company of the moonlight and stars. Rice and beans after the last patient, have never tasted so delicious with a splash of chicken. Working in this environment is very tiring and back breaking, the list of patients is always growing and there is always the fear of not being able to see everyone. Our last family of 2015 had waited for 5 hours to be seen and faced an hour walk back home. Reading their notes from our first dental clinic, the two young boys (Raul and Daniel) had been very anxious and were uncooperative during treatment, but our team had successfully extracted some of their teeth. Having had such a long wait, I was expecting to use my last reserves of persuasion, but much to my surprise the chicos were fighting to be first in the chair. From an anxious patient to becoming a dental assistant was a big step for Raul; armed with head torch and gauze, he diligently cleaned his mum’s teeth as we restored two cavities.

As we were planning to bid farewell to the community of Rio Cana, a 5 year old girl called Natalia presented with a large left sided facial swelling extending up to her eye. She had been unwell for the past two days with a fever and was unable to eat due to the swelling and pain. The team unpacked our equipment and after much reassurance we were able to extract the problematic tooth and drain the dental abscess. This took some of our volunteers by surprise at how much infection could result from one decayed tooth. Moments like these, when we are able to provide care where there are no alternatives and change the outcome of an unwell patient, or witness a positive change in the attitudes of the communities we visit, makes every second spent in our work worthwhile. It has been a pleasure to see the communities embrace our programme and it is very disheartening when no dentists are available to provide dental care.

Our dreams are big for 2016 and in the new year, we will strive to continue and improve our provision of oral healthcare. Plans are in place for a mobile floating clinic where radiographs can be taken and surgical operations can be performed. Agreements have been made to start water testing and implementing water fluoridation in the communities’ water supplies.

Many of the Ngäbe people have been forgotten or must suffer in pain; it is a privilege and honor being welcomed into their communities, to give them the opportunity and education to leading a healthier life. Together with your support we can overcome these challenges and ensure that every child has a toothbrush and toothpaste, no one has to suffer with toothache for over a month, and we are able to provide dental care in a clean and comfortable environment for our patients.

9:00 AM and our clinic is filling fast!

by Dr. Ben LaBrot

I love when our reports are written by our volunteers–their perspective is often unique and I love to have their voices added to support our project, but today I want to personally share an experience with you all.

lots of rain, lots of chest infections to treat

We visit about 25 communities spread over 7,000+ square miles of jungle-covered mountain and mangrove island mazes.  Some of the communities are a shorter boat ride from our base, but some are VERY far away–and the Ngabe community of Rio Caña, where we went last month, is the furthest community we currently visit, on the exposed, open-ocean side of the Bahia Azul peninsula.

Rio Caña is about 70 miles by boat from the nearest small community hospital, and VERY hard to get to–it requires a lot of planning and the willingness to endure pretty bad weather and rough seas to get there.  It is about 6 hours in a huge dugout canoe, at the end of which there is a treacherous river entrance blocked by a sandbar with big surf.  I know longboard surfing is widely popular, but until you have surfed a 50′ hollowed out log down the face of turbulent waves to enter the Rio Caña, you have not truly longboarded.

Shy but trusting, a little girl talks to our docs

In this community, small emergencies are almost always big emergencies–because the chance that the patient may be able to travel to help is VERY low–at best, the trip would cost more than most families live on for 2 months; at worst, bad weather and 15-foot seas make the trip a complete impossibility even if you were a millionaire.  These are the communities we specialize in serving–the ones where a lot of people see a doctor for the first time in their lives when they come to our clinic.

On this visit, there were several ‘small’ emergencies–a horribly infected ax wound on a young man’s foot, a young girl with acute appendicitis, a young boy whose entire scalp was an infected mass of pus and fungus…the list goes on.  All of these things are dealt with in more developed regions by a trip to the family doctor or to the emergency room; here, they are treated mostly with hope, which unfortunately is not always enough to prevent a terrible outcome.

Jungle dentistry: 60+ extractions!

We saw 250 patients, pulled about 60 abscessed teeth, performed ultrasounds on about 25 pregnant moms, and made sure the ‘small’ emergencies STAYED small and were dealt with promptly.

No one who has not shared a journey to distant communities like Rio Caña can truly understand what it takes to make it out there and to provide good health care so far from the comforting presence of a nearby hospital with specialists and advanced services, but if we don’t go out there…the young man loses his foot (and perhaps his life); the young girl’s appendix ruptures and she dies, the young boys’ scalp infection poisons his blood.

Emergency extraction: acute appendicitis

This is why our volunteers endure such hardships to get there, and why we go to such great lengths to reach these communities.  I wanted to write the report myself today because I wanted to bear witness both to the courage of our patients, and to the dedication and endurance of our medical teams.  Am I a hero?  Absolutely not–but I am privileged to work with heroes every day.  Hope in Rio Caña and other communities is no longer the only care available.

The health care our volunteers provide is some of the most loving, caring medicine I have seen anywhere in the world.  In 2016, the infrastructure we have worked so hard to build this year will more than double our capacity.  It has been a tough journey to get this far; traveling to Rio Caña is like a microcosm of the journey of our organization.  When I look back at how far we have come in such a short time, the daunting challenges in the future suddenly don’t seem quite so insurmountable.

a boy brings his sister from far upriver

When someone tells you something is impossible, always remember what Tom Hanks’ astronaut character in ‘Apollo 13’ tells visiting congressmen while giving them a tour of the space center:  “You know, there’s nothing remarkable about us going to the moon.  We just decided to go.”

What will you decide today?

Coming home from the jungle and the mangroves at the end of the year is a lot like coming back to the dock after a long voyage. We see our family and friends (and a hot shower is available everywhere…what luxury), and it is time to take stock of the trip and look ahead to the future.

2014 saw the foundations laid for a huge expansion in 2015—remote outposts were built, new partnerships formed, construction begun on a base of operations, new equipment obtained, and resources developed to allow Floating Doctors to handle an expected 300% more volunteers next year. We saw some wonderful victories, such as obtaining specialized heart surgeries, rescuing difficult births or getting large tumors removed, but we also saw some terrible tragedies that remind us how lucky we are and how precarious and fragile life can be for so many people in the world.

At this time of year, while we visit our families and enjoy the incredible bounty around us, I am grateful for my family’s health, and I remember all the families waiting back in the jungle who face the rainy season without running water, electricity, sanitation or access to basic health care. It is not the wins that drive us to build more, do more, and help more people—it is the losses. The reward we are blessed to receive in this work is the opportunity to help prevent these tragedies, and for this we need your help.

The most frustrating thing is when we hear about one of these tragedies that occurred—all too often—because the patient lacked access to something simple: a child who died because they had no access to a basic antibiotic; a mother who dies of bleeding in childbirth. Conversely, my favorite wins are when a simple intervention changes a life forever. It always makes me think of the old rhyme:

“For want of a nail, the shoe was lost,
For want of a shoe, the horse was lost,
For want of a horse, the knight was lost,
For want of a knight, the battle was lost,
For want of a battle, the kingdom was lost.
So a kingdom was lost—all for want of a nail.”

Most of the time we don’t need a CT scanner or an advanced laboratory or a major trauma unit to save the kingdom—most of the time, we just need a basic antibiotic, or a bag of IV fluids, or 5 gallons of gas. We just need a nail.

Something that costs less than $5 is often the key to saving a life. This year, sign up to help us with just a nail or two each month—with enough nails, we will build and staff more outposts, obtain more medicine and equipment, reach more communities, and help more families end the year by remembering their good fortune instead of their losses.

From all of us at Floating Doctors—thank you for your support, and may this holiday season find you and your friends and loved ones in good health and ready for an exciting 2015.

Fair Winds,

Dr. Ben La Brot

It is difficult to explain the transformation that happens while you volunteer with the Floating Doctors. For the group of us nine medical students there were six months of planning, coordinating, and fundraising topped off with much anticipation and excitement.

Our goal was to teach local providers working with the Floating Doctors how to screen for high-risk pregnancies and heart defects in children using portable ultrasound machines. We planned to study the feasibility of the training as well as help screen as many patients as we could. Our hope was that by empowering local providers with the knowledge and tools to perform these potentially life saving exams, we could leave lasting impact beyond our eight week summer.

Soon enough we were in Panama, working along side Dr. Ben and Floating Doctors doing just that- educating and empowering the locals, and giving them the tools to sustain the improved health of their communities. As UC Irvine medical students, ultrasound is a part of our curriculum. Working with Floating Doctors validated just how useful portable ultrasound technology is in resource-limited settings. We were able to inform a pregnant woman that she had placenta previa, an extremely dangerous condition that can be fatal during childbirth. Floating Doctors provided transportation to the woman from her residence on a remote island to a nearby hospital, where she safely had a cesarean section. She and her baby are alive, and that would most likely not be the case without the ultrasound screening, and without the assistance provided by Floating Doctors. Throughout our cumulative eight weeks with Floating Doctors, we were able to forewarn many women with high-risk pregnancies, and children with congenital heart defects that they should seek attention from a hospital to receive life-saving treatment.

We went into our Floating Doctors experience with a goal- to make a sustainable impact while improving our clinical skills, but we ended up coming out with so much more than that. The greatest lessons learned weren’t which ultrasound probe worked best to assess fetal head diameter or which view of the heart was easiest to get on a small child. The most profound lesson was discovering what being a healer meant for each of us. Everyone goes to medical school for slightly different reasons, but the underlying theme for all of us is that we want to improve the lives of others. When working and learning in the United States it can be easy to lose sight of the human aspect of medicine. Your time is limited with each patient, you send your patients to get X-rays, CT scans, blood tests. To some, a patient can become a list of lab values and radiology reports who can be treated with a medication. Every hospital needs to have the latest equipment to make that list of lab values and radiology reports that much more accurate. But that is not what medicine is about, and working with Floating Doctors helped us remember what it means to be a healer. We made house calls and lived along side the Ngobe people. We got to know each patient as a whole person and took as much time as we needed with each patient. We didn’t close the clinic at 5:00pm, we closed the clinic when there were no patients left. Many times we saw patients into the night with our headlamps as our only source of light. That’s what the Floating Doctors experience, and medicine, is all about: providing healthcare to people in need.

With Dr. Ben and his fearless team as a model we learned what a privilege it was to be let into the lives of people in their moments of need and how as providers we are in the unique position do something to make it better. We have learned that being a healer means doing the best you can with what you can. It means putting in the extra work to figure out what is going on when things are unclear. It means asking for help when you can’t solve a problem on your own. It means being reliable and keeping your word. It means carrying this sense of awe and responsibility with us for the rest of our careers. Our Floating Doctors experience has undoubtedly influenced each and every one of us, and we will all be better physicians because of our experience.

Written by: Amanda Purdy and Jessica Vaughan

Photos by: Amanda Purdy and Jessica Vaughan