Monday, December 28, 2009


I have just read some devastating news. A gastroenterologist known to me professionally has been arrested for fondling his patients while they were under sedation. This is shocking in so many ways. First, there is the betrayal of a sacred trust between a doctor and his or her patient. Second, this man was a very accomplished, scholarly and outstanding citizen, who had even served his country in the Armed Forces. Thirdly, he was a christian, a father who had adopted children from a third world country and one known for compassion and excellence. I have worked in that department and I am not sure how he could be alone with the patient to have indulged in this behavior. There is normally always a nurse, a tech or a family member present. There are always people walking around -- nurses, tech, transport people.

I pray for his family, for his patients -- both the ones who were victims and the ones who are bereft of a good doctor, and lastly for him too. I pray that he finds redemption, repentence and that he seeks for and receives foregiveness and mercy at His Throne of grace.

This is scary stuff. Let each of us examine ourselves and take warning and caution.

The missing urine sample

I worked over Christmas. The day after Christmas a concerned mom brought in a little girl with a fever. I suspected a urinary tract infection as the cause and suggested we get a sample of urine. Since she was not potty-trained, the recommended method for obtaining a noncontaminated sample was to catheterize her. Of course, this is painful and unpleasant, but mom consented, given that it was the best way to be sure this was what was wrong. Two hours after the sample was obtained, I was surprised that a urinalysis result was not back yet. I called the lab and was informed they never received the sample! After several frantic phone calls, the sample was located. It turns out it was not lost. It had been processed both for culture and analysis.

This got me thinking. Snafus happen in every work setting: files get misplaced, entries posted to the wrong account, names mis-spelled, what have you. However, when a sample is obtained at the cost of pain to a little child, it smarts so much if that sample is unretrievable. Clinical information is obtained at the cost of pain and risk to a patient: a lumbar puncture to obtain cerebrospinal fluid, catheterization to obtain a urinary sample, blood draws. I guess everyone thinks their particular work environment is special and I am not exempt from that bias. I'm just glad we found the specimen and could process it correctly. She did have a urinary tract infection and she is being treated. All's well that ends well.

Saturday, December 19, 2009


What a week! I am exhausted in every way. Let me give you the short version as I am too tired to write more for now:
A man with no anus (status post colectomy) -- remember the old advice you got in med school about the only time you cannot do a rectal exam?
A drug-seeking male/female who had undergone a sex change (male to female) with breast implants, -- claims he/she can have sex and orgasms
A domestic violence case with neglected children and a battered wife
An infected artificial knee with large effusion and gout
Too many other things to remember.

I shall be vegetating this weekend...for a while, then I got to go in and catch up with paper work, dictations, billing and letters to patients on labs done, phone calls, emails...ah, the life of a primary care doc!

Isla Bastimentos and the Ngobe

Here is some logistics, facts and trivia gathered on the trip:

  1. There are two schools on isla Bastimentos, one with about 90 kids and othe other with 30 kids. There is no school transport and kids walk to school along the coast. Most do not know how to swim and there has been at least one drowning of a 9 year old recently.
  2. There are Nogbe communities on: Isla Bastimentos (about 2-3 communities), Charcot, La Loma, Salt Creek, Isla Cristobal and Isla Carinero, and on Isla Solarte. There are about 6 huts near the 'Bat Cave'
  3. Healthcare facilities (such as they are) include the hospital in Bocas del Toro, another in Changuinola and a quite decent hospital in David. There is a first aid station on isla Cristobal, Almirante and Charcot.
  4. Transport between these facilities is by boat -- expensive, hazardous and slow.

Medical missions trip to Bocas del Toro

Wild cacao growing on Isla Bastimentos. View of the town of Bocas del Toro from the air.

View from the balcony of the the Kapsars' home The hut where the lady with arthritis lives
  1. on Isla Bastimentos.

    Another view of the same hut A Ngobe village
    I am writing this so-ooo late! During my visit to Panama, I had a memorable visit with Dale and Kim Kapsar ( They live on the island of Isla Bastimentos, one of the islands in the Bocas del Toro archipelago in Western Panama. On this and adjoining islands live a group of Indians called the Ngobe (the 'g' is silent in pronunciation and the 'e' is sounded as 'ay').

    Dale and Kim Kapsar have lived on this island for several years now. Their house itself is quite a marvel, with solar roofing to generate electricity, a rainwater collection system that connects to 2 large tanks to provide running water through the plumbing and a tower to connect wirelessly to existing internet providers in the larger area. Dale and Kim have made Isla Bastimentos their home and the Ngobe their mission field, trying to reach them with the good news about Jesus. They however, are keenly interested in their socioeconomic situation too, developing projects to bring potable water to their communities, local sanitation facilities, teaching hygiene to local school children and providing basic medical care. They encourage support not to give gifts to the local indians, but jobs instead through which they can provide for their families.
    View of some of the less inhabited islands from the air.
    Throug the past year I corresponded with them through email. When I visited Panama to spend a 2 and half week vacation visiting my family there, I resolved to visit them. My family graciously agreed to let me go for 3 days.

    I caught a flight from Panama city to the only commercial airport in the province of Bocas del Toro. Here is a picture of the local airport from the inside. I caught the 45 minute flight and arrived in the town of Bocas del Toro. Dale and Kim received me and we had breakfast in the town. After picking up some supplies, we took their boat, Agape, (shown here with Dale standing next to it) to Isla Bastimentos. The trip lasted about 20 minutes and included a stop at the 'gas station' shown here.

    Travelling among the islands in Bocas is interesting. There is no public pier or dock at the town of Bocas del Toro on the island of COlon where the airport is located. Boat owner who live on the other islands make deals with local residents to tether their boats at the small piers in their 'back yards'. It costs about $ 30 in fuel and takes anywhere from 20 to 40 minutes to go between islands, depending on how far apart the islands are. Since there are no buoys or lights and their are unmarked shallow reefs, travelling in the dark is hazardous. Travelling in torrential rain (not uncommon in the area) is similarly difficult.

    The island shown in this picture is Isla Solarte and the tip shown here is called Hospital Point ( As someone who is interested in the healthcare resources in the area, this perked my interest, hence the photo. Well, it turns out that it WAS the location of the medical center for a banana company that was located in the area and no longer has anything to do with hospitals or healthcare.

    There are numerous mangrove islands that are quite beautiful to look at and here is a picture of one on the way.

    The picture below shows Isla Bastimentos and the Kapsar's home located on higher ground.

    When we arrived on the island, our first stop was in a small, half-finished building that will (we hope) eventually become a local clinic. Living there presently was a family, one of the members of whom works for the Kapsars. One the phone the day before my flight to Bocas, the Kapsars had told me of a little boy called Aljillo. This was a 2 year old who weighed about 15 pounds and did not walk. He was very malnourished. Here is his picture.

    As we walked off the Kapsars' boat, visiting him was my first stop. He had evidence of malnutrition, scabies, lymphadenopathy everywhere I looked. I treated him with something for worms, another pill for parasites, an intramuscular dose of a broad-spectrum antibiotic and gave the family a multi-vitamin and iron syrup to give him daily. I also recommended passive range of motion of his extremities. Within a few days, his lymphadenopathy had subsided and he was ravenous.

    After I left, a YWAM (Youth with a Mission) team continued to care and before they left, this little boy was walking! It turned out that the family was not feeding him because he was born out of wedlock. We tried to arrange to get him into a Nutri-Hogar (a home run by the catholic church on the mainland that provides nutrition to malnourished children before returning them to their families.). However, the family left before we could do this.

    Later that day, we visited a local school and participated in a group discussion on how things were going with the newly constructed latrine. The following day we visited a local village and saw several children. I treated impetigo (click on the picture of the little boy and look closely at his face, near his nose), scabies and one elderly woman with severe arthritis. The day before I left, Dale cut his hand and I was able to teach Kim how to suture lacerations -- a very common problem they must deal with.

    Teams that have come before me have left medical supplies and I left my stock of brough antibiotics, and supplies too. Here are pictures of my flight back home.

    Coming back to Panama I began to research what is known about the Ngobe and their health problems. Infant mortality is highest among the Ngobe compared to the rest of Panama and it is clear to see why. Most of the children are born at home or in the cayuco on the way to the only island with a 'hospital' (which is a very minimal facility run by the MInistry of Health).

    Here is the vision:
    The Kapsars are willing to give that little building on Isla Bastimentos to become a clinic / hospital
  2. If we can get 21 doctors/nurse practitioners we can staff the clinic/hospital the year around.
  3. Each provider would spend two and half a weeks at a time on the island.
  4. They would be able to live with the Kapsars in their house. (It is a great place with electricity and running water). However, they would pay for their room and board and bring along what medical supplies and equipment they can.
  5. There would be a half week overlap between changing providers for a 'sign out'.
  6. Contact between all members of this 'group practice' would be by email and if bandwidth on the island ever permits, video conferencing or at least pictures.
  7. Once a year, we would all try to meet someone and discuss our 'practice'.
  8. Each physician would return yearly.
  9. There would be periodic visits from church supported mission teams that would help with constructions projects and mass medical camps, but our group practice would provide the continuity, follow-up and guide the incoming camps to identified areas of needs.
  10. This vision would provide continuity of care, an established presence among the Ngobe and U.S. standard of care.
  11. I am signing on as the first doctor. Any other takers?