It was way too early. At 5 am I sleepwalked my way through breakfast and put on my headphones to listen to some Pearl Jam and broke out the book “Three Cups of Tea” about Tom Mortenson and his success in building schools for children in Pakistan. I needed some motivation to get through this upcoming 72 hours ashore in Colombia. We repeated the drill of getting from boat landing zone through town, and to the medical site. We were again greeted by droves of waving young children and adults waiting to be seen by U.S. medical providers. I asked one woman how long she had been out here and she responded “a las dos de la manana” since 2 am in the morning. Heck she should have just camped out overnight.
With thousands of patients to be seen, a hard rule was laid down by the government that they had to make a choice of what problem was bothering them most - and that is all they could be seen for. So for instance if a patient came in and was treated for back pain, and they also needed reading glasses, they were not permitted to go to optometry to get those glasses. The surgeons were also completely booked up on the ship, and we were told no more surgical candidates would be considered. This set the tone for the days to come. I closed my eyes and mentally checked myself, preparing my mind for the upcoming discouragement. I needed to put on my 3rd world glasses and make myself believe that simply seeing these patients and providing them with some basic medications would make a difference in their lives.
The translator I was assigned today was a young 19 year old girl named Maria from Bogota, Colombia. I noticed right off the bat that she was quite shy and I tried to help her feel at ease by offering her some coffee and some items from the MRE for the day. I explained to her that the best method of interrogation for these patients is if I say hello and introduce her and then she fires off the questions as I fill out the encounter sheet and offer my advice and she translates it back. This technique I noticed worked best because it makes the translator a type of “buffer” and compassionate bearer of the bad news. Even though I understood most of what was being said by the patient and could have spoken more, to have someone from their own country say “the U.S. doctor apologizes that he cannot help you more, but he can offer you pain medicine and vitamins” seemed to be more effective and less devastating for the majority of patients. I introduced Maria as “mi amiga” (my friend), and “mi emfermera” (my nurse) which I noticed she took a lot of pride in after seeing a number of patients. As we got more comfortable working together she became more and more engaged with the patients. I have a lot of respect for these translators who are volunteering their time to do this service. Every so often Maria’s friend and fellow translator Carolina every once and awhile would pop her head into the exam space and say hello. Carolina had a very warm presence about her and a beautiful smile. She is the vision of what I always have had in my minds eye of a Colombian woman- slender, with olive skin, long dark hair, and gorgeous brown eyes. She had a Roman Numeral II written after her name and I asked why? Turns out that one of the other translators name was also Carolina Pinzon. Lots of commonality of names down here in Colombia. I think the name I have seen the most repeated is Maria.
Maria and I had a good system down and we were seeing patients at lighting speed. Most had good attitudes and just wanted their pain taken care of, or some medicine for a rash. I made a point to ask every patient what they ate, and what sort of activity they did. If they smoke or drank, I came up with a plan for them to stop. Everyone was told to drink lots of water, no sugar or postres (cake), and went through a stretching routine with me before they were allowed to go pick up their medication and vitamins. They also were not allowed to leave until they responded to “dame una sonrisa” (give me a smile).
I must have been getting low on blood sugar, or just couldn’t deal with the heat, or the incessant claims of no money and no health insurance, but late in the morning I snapped while seeing a patient with an infection in his middle finger after a botched orthopedic surgery repair of a complex fracture. The man carried his X-rays with him and was basically dripping pus from his infected hand all over the folder containing them. This would never happen in the United States. “Why didn’t you go back to have it fixed”, I asked? The man replied that he didn’t want the surgeons to mess his hand up more, and that he was scared to go back. I squeezed more pus out of the wound and stared at the gentleman’s middle finger which took about a 45 degree turn midway at the proximal joint. This was simply UNSAT (what we say emphastically in the military for unsatisfactory). Normally I would incise this wound and drain the pus and put him on strong antibiotics, and then get him into surgery ASAP to fix his hand. In this situation, my hands were tied with no more surgeries allowed and limited ability to do minor surgery here in the field. I tried to get as much of the pus out as possible and instructed the man to keep it extremely clean, and take the full course of antibiotics that I gave him. And then I struggled with whether to tell him to go back to the surgeons that had botched his repair in the first place. The man said he was willing to wait two years for when and if the COMFORT ever came back to have it done then. And he said “voy a llegar al primer dia” (And this time I will get here the first day to sign up for surgery).
After seeing the middle finger guy, I was ready for a break and some lunch. The lack of follow-up and good care made me so mad that I again had to close my eyes and talk myself down. “Don’t get sucked in to each case, dissociate yourself from it Andy, look at the big picture” With that I shook it off, and decided to go talk with some of the locals who were selling different types of fruits by the roadside. A man with a machete cut open some oranges and papayas and I paid him a few pesos for some. He also sold me some “zapotes” which after tasting them are a bit like sweet pumpkins. I then splurged and at the corner stand had the nice Colombian ladies give me an ice cold bottle of Coca-Cola to be drank with a straw. Ahhhh that hit the spot.
The afternoon was again filled with much of the same, and I tried to focus on the positive cases and doing as much as I could. I was getting tired. The lack of sleep the night before was truly taking its toll as evidenced by the Colombians complete and utter inability to understand my tired Gringo Spanish. A woman came in who was deathly skinny and who had eyes that bulged, and I immediately narrowed down the diagnosis to either anorexia, hyperthyroid (Graves disease), or a big parasite in her gut. The most likely cause was a hyperactive thyroid and so I looked on the pharmacy sheet for the medication to give her and it was nowhere to be found. Can’t even give her what she needs and it would only last her a bit of time anyways…. I walked over to the pharmacy to make sure and yes indeed, no PTU.
I pleaded with her to go and see a doctor here in Colombia. She said she couldn’t afford it and didn’t have health insurance. Doesn’t your husband? She wasn’t married. Doesn’t your work provide? I don’t have a job. I looked into this woman’s eyes and realized the reality of the situation- she was going to die soon because she simply did not have access to care.
I needed an ice cold beer.
Luckily we were headed to the hotel Villa del Sol that evening, and after about two hours of waiting for the bus and the room, we were able to change out of our sweaty uniform and dirty boots, grab a cold shower (no hot water), and crack open a semi-cold bottle of beer. Whew it had been a long day.
Dinner that evening at Villa del Sol was delicious compared to the Ship and the MREs and so we savored it. We also welcomed the chance to watch CNN International on the TV in our room and heard about the killing that had occurred at the Holocaust Museum in Washington, D.C. My roommates for the next two nights were Pediatric Neurologist and Air Force Major David Hsieh and Navy Commander and Family Nurse Practictioner Jim Keilak. All three of us supposedly snore, and upon realizing this we wished we had a tape recorder to capture the orchestra of sawing to come that evening.
As we lay down to sleep on rock hard mattresses we inspected for bed bugs. By visual inspection I decided my bunk was good to go. Jim took a bit more caution and sprayed Permethrin all over his bed. Can never be too safe I suppose…. Jim had turned the Air Conditioner on a few hours ago, and there apparently was an issue because the thing started leaking water all over the floor. We placed a bucket underneath and hit the wall panel in which it was installed a few times, and it stopped leaking for a bit. But as my eyes closed for the night I heard drip…..drip……drip……