Nica and I are back in the USA and just had our Match Day yesterday. Match Day is a nationwide event where medical students across the nation simultaneously learn where they will be spending their next several years of residency training. I have been dreaming of doing Emergency Medicine residency in New York City and Nica has been dreaming of doing Pediatric residency in the southeast. Well. We both got our wish!!! Nica is going to be a peds resident at Duke University and I will be an EM resident at New York University!! We are beyond excited. 😁
Author Archives: Chris Pham
VI.I Emergency in Cayo de Agua
During our first clinic day in Cayo de Agua, I had just transitioned over to the provider role when I heard our clinic manager Jack discussing a potential emergency home visit that would need to be done. Apparently somebody had come to clinic asking if we could see her aunt in her home emergently. As soon as I heard this I beelined to Jack and asked if I could be a part of the visit. He agreed and said I could go with Anne – a Dutch pre-clerkship medical student – and Eliza – a surgically focused physician from the Netherlands.
All that I had heard so far was that this patient was experiencing severe chest/abdominal pain (unclear which at the time) and had seen us once before several years ago – so no recent medical history. I began racking my brain for what could be going on and trying to prepare a go-bag of tests and whatever medications we may have that could be of use – intake supplies, portable EKG, aspirin, analgesics, anti-emetics, etc. Unfortunately we no longer had access to a portable ultrasound which was a huge letdown (and another motivator for me to go purchase one of my own).
Once Eliza was ready, she, Anne, and I followed this girl to her home. The story that we were told was that her aunt had severe pain in chest/stomach and could not get up for the past several hours. Along the way, Eliza told me that she remembered I plan to specialize in emergency medicine so she would sit back and supervise as I ran the case and Anne performed intake. I was so grateful and excited for the opportunity.
After a 10-15 minute hike to this patient’s home right on the water, we entered their home which was full of people and found our patient lying on her cot on the floor – sweating and clearly in discomfort. In Emergency Medicine, one of the first questions you learn to ask yourself and intuit is “is the patient sick or not sick?”. This patient was sick. I knelt down and introduced myself and the team and began the visit. With several questions and suggestions interjected by Eliza, we quickly came to the conclusion that she very likely had acute cholecystitis (inflammation of the gallbladder) and was in need of emergency surgery. As soon as we realized that she was likely suffering from cholecystitis, we were wishing that we had access to an ultrasound because cholecystitis can be evaluated and confirmed via ultrasound. However, we had to trust our clinical judgement and we knew that regardless she needed to be sent for surgical evaluation.
In Holland or the USA this would have been a simple case with a phone call to the on-call surgery team. However, we were presented with a whole host of social issues to overcome. The family had no money to afford the trip to the city for surgery. The family had no money to afford the surgery. The family had rarely ever gone to the city and was terrified of navigating it alone. We didn’t know if/when we would be able to follow-up with the patient. We didn’t know if we’d even be able to convince the doctors in the city hospital that she does in fact require surgery. We included the family as much as possible in our thought processes and told them that we would return in an hour or so after consulting with the rest of the FD team on how to proceed.
We made the hike back to clinic and reported to our provider in charge for the day along with our clinic manager who has more understanding of the local healthcare system than anybody else on the team. Eventually, a decision was reached. Our plan was to bring the patient and one family member who can care for her. She would be picked up by one of our boats at her house and accompanied the entire time by Eliza and one of our other FD staff members who was still at base. FD would fund as much of the patients transportation and medical costs as possible. The patient would be followed-up with in two weeks when FD returns to a nearby village for another clinic. And to make up for the loss of one provider (Eliza) for the remainder of the clinic week, Nica and I would fill in as providers (while still reporting to a supervising physician, of course).
After we returned to base clinic on Thursday, I anxiously awaited an update from Eliza. As it turns out, the patient was initially discharged from the ER when they couldn’t find anything on ultrasound. But that evening, she decompensated again (in the city) and was brought right back to the ER at which point they agreed that she was in fact suffering from cholecystitis and scheduled her for a cholecystectomy first thing in the morning. She had the surgery done laparoscopically and tolerated the surgery extremely well and recovered and was discharged within a couple of days. Eliza and one of our other FD staff members – Kevin, who is from the city that the hospital is in – accompanied and advocated for the patient and her mother the entire time. This ended up being such a help because of the social issues mentioned prior. I am truly grateful that they were able to be there with them.
Two weeks later, I’m back on my couch in my living room in Atlanta, GA, and I receive a text from Eliza. She had a follow-up appointment with our patient and she says that she looks like an entirely different person (in a good way).
VI. Multi-Day Clinic in Cayo de Agua and Quebrada Sal
After yet another fun weekend of exploring the beautiful, natural islands of Bocas it was time for Nica and me to start our third and final week with Floating Doctors. This week we were heading to Cayo de Agua for two days of clinic followed by a day of clinic in Quebrada Sal (Salt Creek). Nica and I had certainly felt more comfortable in transitioning to the provider role this week but we had no idea how much was in store for us during this final week.
We started off our week on Sunday by meeting several new volunteers from the Netherlands – one physician, one nurse, and two pre-clinical medical students – and another returning volunteer – an ER nurse from Canada. They were all extremely excited to start with FD. Twinges of sadness crept in as we watched them receive the tour of base that we received what felt like months ago but was only two weeks prior. We viewed this as an opportunity to offer any mentorship we could do the new volunteers to ensure the incredible spirit of FD continued.
On Monday we packed up our lunches, loaded up both the cayuco and the panga and set sail for Cayo de Agua – a 2-2.5 hr ride. We had nice weather for our ride out, but that certainly didn’t stop the wakes of the boat from splashing us thoroughly for the entirety of the ride. We were soaked by the time we arrived, but we didn’t care because we were welcomed with an incredible view of a village immediately on the coast.
As soon as we had arrived and unloaded, we got to work with clinic. Nica and I were each assigned to start the day on intake station with a new Dutch medical student volunteer paired with each of us. Having been in their shoes and skill-levels at FD only a couple of years ago it was quite special to get to come full circle and mentor them in medicine and the flow of FD the way we were mentored by our senior peers. We had the opportunity to work with each of the new volunteers and were impressed by the work ethic and spirit of all of them – a testament to the type of people that FD attracts.
By mid-day we could tell it was shaping up to be a crazy busy clinic day full of lots of patients and complex (time-consuming) cases. Our providers were swamped. During lunch our clinic manager Jack came over to Nica and me and asked if we’d be willing to go ahead and transition to providing. We immediately consulted with our respective intake partners to make sure they felt comfortable running intake alone. They both said yes, so Nica and I swapped over to providing.
As always it felt great to be back in a provider role! As the weeks have gone on we’ve felt slowly more and more autonomous and confident in our ability to provide and help. It was always funny to pull a patient from the provider queue that we had done the intake on. So essentially we’d introduce ourselves twice – the first time getting their vitals and a brief story and the second time as the provider who is actually going to address their concerns.
The day was moving along when I heard that there was an emergency home visit that needed to be done. I immediately went to Jack and asked what was going on and if I could help with the emergency. He agreed and had me wait for the other provider who would be going with me – Eliza. I’ve included a link to a more detailed account of the emergency case here. But for the sake of brevity, I’ll say that it was a true emergency and an extremely meaningful case that I got to play a large role in. After the case was done, we were down a provider for the remainder of the week because Eliza accompanied the patient to the hospital. As such, Nica and I were called upon to serve as providers for the remainder of the multi-day clinic week.
Once the first day of clinic came to a close everybody was totally exhausted. It ended up being one of our busiest days. However we had something fun to look forward to in the evening. Some of the patients had invited our group to go join their volleyball game that evening, so we made a 15 minute hike to their volleyball court just before dinner. Some of us joined the game and had a great time while others of us (Nica and myself included) were very content to watch and play with the kids and not get sweaty before bedtime. After dinner and sharing sodas at the tienda, we all conked out in our hammocks.
We started our next day in Cayo de Agua waking up with a beautiful coastal view that was truly special. As Jack prepared us for clinic and went over assignments, he re-assigned Nica and me to intake with partners. However he gave the caveat that as soon as we saw the provider line getting long or we felt ready we could transition over to providing. Nica and I were beyond excited. As the day started, my intake partner Sterre (a neurology nurse from the Netherlands) and I were working so well and efficiently together. It wasn’t long before we realized that the intake line had grown short and the provider station had become the bottle neck. So to transition, Sterre and I began doing intake/providing on patients (start to finish) which was such a pleasure to have her to bounce ideas off of. Eventually, both the intake and provider lines grew, so I confirmed that Sterre felt comfortable enough in her Spanish to do intake on her own and transitioned over to providing on my own (with a physician supervising). I noticed Nica was making the same transition and we began working our butts off. There were several moments when we looked at each other and had proud moments of appreciation for how we had both come since the last time we were here.
Thankfully, the rest of the day ended up going fairly smoothly without any crazy unexpected surprises like the emergency patient the day prior. Nica had certainly settled into her pediatric niche and was taking every pediatric case that she could get her hands on and knocking them out of the park. Towards the end of clinic day, the lead provider came up to us and asked if we wanted to do a home visit together. We realized that we had not yet worked with each other once and were so excited for the opportunity. We both agreed and went on a home visit (which was only 100 feet or so away) for a blind, chronic patient of FD. The case ended up being relatively straightforward but it was nevertheless special to provide care for a patient with each other.
After clinic finished, we held another charla with one of our closest friends made at FD – Konrad. As I’ve mentioned before, FD is making a public health education effort in its communities and Konrad is the spearhead of these efforts. At this point in time, he is working hard to develop charla’s for numerous other topics including dental hygiene and nutrition. We are still keeping in touch with Konrad and excited to see what he puts together over the course of his year with FD. We truly believe in the power of public health education in these communities and in populations in general.
After our charla, we packed up the boat and headed over to Quebrada Sal (Salt Creek). Quebrada Sal is another beautiful village near the beach that is a 10-15 minute hike from the boat dock which makes unloading heavy pelicans and boxes of rice a fun challenge. It was just a little before dinner time by the time we finished unloading the boat. Several folks decided to make the ~15 trek to the beach for the evening. A few of us (Nica and myself included) stuck behind to try to get a freshwater shower – something we hadn’t had since we left for Cayo de Agua two days prior. We managed to get a shower using somebody’s shower pack which is essentially a backpack that fills with water and has a shower head nozzle that spouts water with gravity. It was honestly one of the most appreciated showers of either of our lives.
The next morning, we woke up and got ready for clinic again. The day started off very similar to the day prior with Nica and me working intake until we were ready to provide. As it turns out, however, the patient population at Quebrada Sal had some relatively complex pathology and there simply were quite a lot of patients. The day quickly evolved into our most hectic and busiest day at FD yet. Nica and I moved to providing rapidly to help ease the load and we were seeing everything from machete wounds to non-specific, complex urinary complaints to a whole array of complex pediatric diseases and infections. I even had the opportunity to do a new patient home visit as the sole provider with Iona – a Canadian ER nurse volunteer – accompanying me. However, one of my absolute favorite moments of the day was when I overheard one of the lead medical providers saying, “hmm. I need a pediatric consult for this complicated child.. Does anybody know where Nica is?” At the end of the day Nica and I looked at each other and we could both see that the other was exhausted yet feeling totally accomplished and content with the work we had done. It was a fittingly crazy and satisfying last day of clinic for our last clinic day of FD. Or at least, we thought it would be our last day of clinic with FD. More on that later.
One other interesting thing about Quebrada Sal is that it is located relatively near a beach resort that has a publicly accessible beautiful beach. After an extremely long and tiring day, all of the Floating Doctors team swung by a tienda, picked up an ice cold soda, and trekked to the beach to relax and unwind.
We had a delicious dinner that evening, reflected on a busy day, played a fun Dutch card game provided by fellow volunteer Rose – a Dutch physician – and turned into our hammocks for the last time. The next morning, we were heading back to base.
Once we arrived back to base on Thursday, we got to work on pharmacy tasks to prepare for the next week. Those were over within a couple of hours, so Nica went to the dock to kick back and relax while I went to go play a game of volleyball with Fermin, Kevin, Quentin, Jack, and Konrad.
On Friday, Nica and I were asked to man the weekly base-clinic since it was our last day. The day started off quiet with no patients which was an ominous sign for what was to come. As base clinic hours was coming to a close, I was notified that a patient came in with a big gaping machete wound across his palm – suture time. Nica was gracious enough to let me take that case since she knew that was more in my domain of interest. And it’s a good thing that she did because not two minutes later, several children and their mother showed up seeking consults. So as our very last hours at FD were coming to a close, I’m performing an E.R. procedure while Nica is handling multiple pediatric patients at once. We worked through lunch to finish everything and felt so satisfied that we did. It was a perfect last case for each of us on our last day of Floating Doctors (for now).
Our time at Floating Doctors has always been and always will be truly special. We’ve met some of the most incredible people here (staff, volunteers, and patients), gained so many formative life experiences, and truly felt like we were able to use our passions for the benefit of others in a safe, responsible way. We hope that Floating Doctors continues to do great work and serve its communities to the fullest. It’s always a pleasure to play a part. Until next time, Floating Doctors. Fair winds.
~Chris & Nica
V. Single-Day Clinic Week in San Cristobal and Tierra Oscura
After a fun weekend in Bocas Town, Nica and I returned to base Sunday evening to prepare for the next week of clinics. Our week started with a day on base on Monday organizing the pharmacy and packing our cases for clinic this week and next. You can tell that we were all return volunteers because we really hit our stride with our work and got all of our tasks done in record time. Nica and I also saved a bunch of expired sutures to practice and teach suturing to others on base!
After a long day of chores around base and several informative lectures from the staff physicians, we relaxed in the afternoon before dinner. Nica went to the dock to have a refreshing swim/snorkel while I played volleyball with a few of the staff members. Needless to say one of us was refreshed and one of us was extremely sweaty for dinner.
The next day was our clinic day in San Cristobal. This village is on the same island that our base is on – Isla San Cristobal – so our commute was only 10 minutes. It took longer to pack/unpack the boats than it took to travel. We had started clinic by 9:30am.
The day started like usual for Nica and me. We were both working our own intake stations and we were flying. Nica and I had definitely found our rhythm again and were working through patients faster and more thoroughly than we had before. Many of our patients here come for depo injections which we are allowed to handle ourselves without them ever having to see a provider. Within the first hour Nica and I had each fully manged 4-5 of such patients.
After lunch, Nica went off to do home visits with one of our excellent staff doctors from Argentina – Fermin. She and Fermin saw three elderly patients in their own homes and provided care on-site since traveling would be difficult for those patients. It was great to see the actual livinig conditions of their patients so they could provide more tailored care and recommendations. They were able to provide a walker for one elderly gentleman who had gone blind and was having difficulty navigating his own home.
Meanwhile I stayed in clinic and transitioned from an intake to a provider role. My first patient that I saw on my own ended up being a fairly complex patient with multiple issues needing management including colicky abdominal pain, chest pain, arthritis, and several other chronic issues. As it turns out, her abdominal pain was being caused by a gallstone that we were able to catch using a provider’s personal portable ultrasounds. It was so exhilarating to catch a gallstone using ultrasound in the field. We gave this patient medication for her pain and a referral for surgery. She was so pleased that we had finally found an explanation for this pain she had been suffering from.
The next day we rinsed and repeated by going to another nearby clinic called Tierra Oscura. All the staff were very excited to return to this village because there is a dog that is well known to Floating Doctors. This pup will, without fail, be at every FD clinic every three months and greet everybody with a hug. The clinic was not too busy that day, but that didn’t stop Nica and me from having great days working as intake/providers and growing more and more comfortable. Funnily enough, we had yet another gallstone patient that we caught with the ultrasound – just a day after catching one.
Since we only had two clinics this week, we had an extra day to ourselves during the week. As a special treat, our volunteer coordinator organized a trip to a local finca (ranch/farm land). One of the staff chefs at FD base lives in a nearby village and owns a finca up in the mountains where she grows sugar canes, cacao, and many other delicious fruits. We strapped on some rubber boots and set off on a surprisingly grueling but stunningly beautiful hike. We reached the finca at the top of the mountain and were greeted by a herd of her cows who were less than pleased with our presence. We kept our distance from the cows. Once we reached the top we piled into our guide’s house to rest, eat our sandwiches that we packed, and indulge in some delicious sugar cane, soursop, and cacao fruits.
IV. Multi-Day Clinic in Nance de Risco and Rio Oeste
Monday of our first week finally arrived which meant it was time to head out to clinic! We run clinics every week to different Ngäbe villages in the surrounding area and we make sure to visit the same village every 3 months so we can follow up on care. This week was a multi-day clinic week which is when we go to villages that are so far from base that we stay overnight so we can run multiple days of clinic.
The morning starts with some coffee on the dock of base watching the sunrise before breakfast. After breakfast all the volunteers grab their travel bags and head to the pharmacy to start loading the cayuco. Because we want to be as close to a fully functioning mobile clinic as we can, we bring a literal boatload of supplies including medications, wound care supplies, giveaways (i.e. toothbrushes, soap, hand sanitizer), and boxes of enriched rice for malnourished children. You get a weightlifting workout working at FD.
Once the cayuco is loaded we all pile into the boat and set off for our first destination. This week our first village was Nance de Risco. It’s a beautiful village nestled in the mountains. To get there we have to take a boat to the main port city (Almirante) then hop in multiple vans that take you up winding dirt roads to get to the village. As soon as we arrived we started to unpack the vans and get straight to work setting up our clinic.
Every clinic day starts with a huddle where the clinic manager (Jack) gives announcements and assigns roles for the day. Nica and I started our day running the intake station which entails getting basic medical history from each patient, collecting vital signs, and asking the patients briefly what they want to discuss with the provider.
After a lunch break, Nica and I got close to finishing all the intake patients and began to transition to a provider role which we had been so excited about since our first time coming to floating doctors as first-year medical students in 2019. We finally got to use years of studying and work to provide for these patients in the highest capacity we could. We saw everything from bread and butter hypertension & diabetes to tropical GI parasites and festering wound care. And a plethora of OBGYN care. One of the new improvements that we noticed was the incorporation of public health education for the communities. This included teaching villagers about prevention of dehydration and lifestyle management for chronic conditions. These charlas (discussions) have the potential to make long lasting impacts in the communities.
After a long day of clinic, we begin to pack things up and start winding down our day. The next goal on everybody’s mind is to get the sweat and grime off with a clean shower. Well the closest thing we have to that is a river running through the village. We all pack up our shower gear and hike to the river for a refreshing dip.
It’s finally about dinner time and we are starving. At every multi-day clinic we have a family who we hire to cook our food for us for the days we are there. We bring our own ingredients in a Yeti cooler. Meals typically consist of a grain (rice or quinoa), chicken, and beans or lentils. The food is always excellent and there is a local hot sauce called Bocas Sauce that is delicious and a staple of spending time with Floating Doctors (or in Bocas del Toro in general).
We also got a special treat in the Rio Oeste village where our amazing clinic manager Jack is from. Rio Oeste is a large producer of cacao and sells incredible, fresh cacao in numerous forms (nibs, baking bars, tea). The cacao was incorporated into all of our meals there which was incredible.
Last but not least it’s time to sleep. Earlier in the day we had set up our hammocks in local ranchos or buildings so we could sleep through the night. I can’t say it’s the most restful sleep ever but it really is an experience you never forget. Although we all could’ve done without the loud barking dogs and roosters at odd hours of the night.
After two days in Nance de Risco and one day in Rio Oeste (three hammock nights total) we finally head back to base. We round the week out by doing some chores around base (restocking the pharmacy and supplies for the next clinic, filling prescriptions, etc.) Then on Friday we are free to head into Bocas town to enjoy the weekend to ourselves!
III. The Return to Floating Doctors
We made it. We finally made it back to Floating Doctors base. Floating Doctors’ (FD) base is a beautiful self-sustaining base of operations set in the mangroves of San Cristóbal Island. It’s a 30 minute boat ride from Bocas town and there’s a boat that leaves Bocas for base every Sunday at 5pm. Thankfully we both tested negative for COVID right before boarding the boat so we could both be permitted on base!
We met three other volunteers – Sophie from Austria, Ashley from the USA, and Mariëlle from Holland – along with other staff members from all over the world returning to base after a weekend in town. It was so great to be back among such a diverse group of people who are so passionate about culture and global healthcare.
II. Traveling to Bocas del Toro
We woke up at 7am to catch a flight to Bocas del Toro. We flew out of the tiny domestic Albrook airport in Panama City in a fittingly tiny airplane.
After an hour airborne, we were back in beautiful Bocas del Toro. We spent the rest of the day at a local hostel relaxing and enjoying the views. And the hot water/reliable plumbing – two things we wouldn’t have much of starting the next day…
I. Traveling to Panamá City
Nica and I began our day by meeting at the Atlanta international airport early Friday morning to catch a non-stop flight to Panamá City. Unfortunately we couldn’t make it in time to catch a flight the same day to Bocas del Toro, so…
… we decided to make the most of our layover day and see what la Ciudad de Panamá had to offer!