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“We think there’s a possibility we might have a case of Pott’s disease,” Dr Allain Sebastian stated, his nose buried in a medical chart. Allain was second in command of Killian Hospital, after Isabella Mordecai, who was the chief of staff there. Paul had made the decision to leave the medical workings of the hospital in their capable hands when it had turned out that he had been spending more and more time away. It had been a good decision, too, because they were a dynamic team. Hardworking, smart and, best of all, dedicated to the kind of care the hospital stood for.
“Allain’s from an infectious disease program out of Boston,” he explained to Solange, as they both donned masks before entering the area of the patient wards. It was protocol. Universal precautions, no matter what the situation. Better safe and inconvenienced in some instances than sorry. “When he heard about all the perks we offer here, he couldn’t wait to apply for a job.”
“Perks!” Allain snorted, fighting back a grin. “Long hours, no pay. And the accommodations…I gave up a townhouse with a Jacuzzi for a room with a sink.” He winked at Solange. “What more could a man want?” He extended his hand to her. “I’ve been on my feet sixteen hours already and I’ve barely begun.”
“Believe me, I know those hours.” Solange laughed. “My name is Solange Léandre. Dr Solange Léandre. And, no, I’m not here to work.”
“That’s too bad, because I was already looking forward to eight straight hours of uninterrupted sleep tonight. Haven’t had one of those in months. So, are you open to bribes, Solange? Anything I own just to have you cover one shift for me.”
Solange smiled first at Allain, then at Paul. “I’m usually open to bribes, especially lavender soap and lobster dinners, but since I’ve had my share of those recently, I’m afraid I wouldn’t be awfully susceptible right now.”
“Lavender soap and lobster dinner?” Allain raised a skeptical eyebrow at Paul. “Don’t think I’ll ask.”
“Don’t think I’d tell even if you did,” she replied, smiling shyly at him. She could feel the heat rising in her cheeks over the ideas Allain was forming, ideas she’d had herself.
“Well, I do have a fondness for lobster, if you should ever have any left over. Don’t care much for the lavender scent, though. At least, not on me. So, Solange, is this a social call or a professional one?” Pudgy and short, with a ruddy complexion and red hair, Allain Sebastian stepped back and appraised both Solange and Paul. Then he gave them a big, toothy grin.
“She’s here to demand one more hour a day from you,” Paul teased, faking a frown.
“Stop that!” Solange laughed, hitting playfully at Paul. “It should only take half an hour of Allain’s time. You’ll have the good doctor thinking I’m quite the mercenary.”
“And just when I finally quit believing all those rumors about the pirates on the Caribbean seas,” Allain quipped.
“It’s not quite a pirate’s ransom that I want,” Solange explained. “Just a few routine tests for my patients whenever the need arises. I have a little medical infirmary up in the mountains, and I don’t have the facilities for X-rays and lab work. I came to make arrangements here.”
Actually, Frère Léon had insisted she make the arrangements and had practically shoved her off the side of the mountain to get her to do it. Now she was here, she was glad she’d come. This was a wonderful facility. Neat, tidy. Clean. Paul was terrific. Allain was, too. And it was nice getting herself back into the medical community, around doctors, after being away from it this past year. Even if this was just a cordial acquaintance since she would rarely, if ever, have the need to come here again in person, she was enjoying the camaraderie. The working dynamics here were good, and the chumminess fun. Nothing like her last months at her clinic in Miami.
“Well, for your patients, Solange, I always have an extra half-hour. But in the meantime, I need to get back to that possible case of Pott’s because, to me, it’s just not quacking like Pott’s.”
“Quacking?” Solange asked.
“Quacking,” Allain repeated. “You know the old saying, ‘If it looks like a duck, and it quacks like a duck…’”
“Then it must be a duck,” Solange supplied. “And your Pott’s disease isn’t quacking like Pott’s disease.” Pott’s disease, a form of tuberculosis, occurred when the TB bacillus escaped the lung and traveled throughout the body and lodged in the spine. It was a common occurrence, and in the Caribbean the leading cause of paralysis in young men.
“Something like that. He has the right symptoms, especially the paralysis below the waist. But he’s latent.” Latent TB, meaning he tested positive for exposure to the disease but didn’t have the actual disease. “And I couldn’t find any significant case history of Pott’s in latent TB.”
“Well, you’re right about that. You don’t normally see Pott’s in latent,” Solange replied. Then she deferred to Paul. “Sorry. I shouldn’t be stepping in here. I’m just the visitor.”
“The visitor who’s welcome to step in any place, any time she wishes,” Paul said, gesturing for Allain and Solange to follow him to the small, two-bed room where the patient, Agwe Bourg, was snoozing quietly in bed. “We don’t really have any kind of a medical hierarchy here so, by all means, step in, comment, offer opinion, order tests. It’s all welcome.”
“Why do I get the feeling that I’m working?” Solange asked, laughing.
“Because Paul’s like that. He just sneaks it in on you. And watch your pockets, Doctor. He’s been known to pick a few of those on occasion.”
“You left out the part where I make you think it was your idea to have your pockets picked,” Paul added, opening the door and walking straight to the bedside of Agwe Bourg, a man, probably in his mid-thirties, who had a wife and seven children depending on this diagnosis. “So in spite of Mr Bourg’s being latent, why would you suspect Pott’s, Dr Sebastian?” Paul asked, keeping his voice low so not to disturb his patient.
“Like I said, he has the latent diagnosis, which puts him close to the disease. Maybe not right on it, but definitely close. And he does have the other symptoms—paralysis, general malaise.” He drew in a deep breath, then let it out slowly through his mask. “But it’s not Pott’s. At least, that’s my gut instinct.”
Paul nodded, but said nothing, so Allain continued. “He’s in the right age category, though, so that’s not a rule-out.” Often, diseases that were difficult to diagnose were given a final diagnosis by ruling out other conditions and symptoms. Rule out enough factors, then take a good hard look at what was left.
Paul nodded again, looking down at Agwe Bourg. “Fever?”
“Yes,” Allain said.
“Weight loss?”
Allain nodded. “He says he has no appetite, and we haven’t been able to get him to eat a thing.”
“Cold abscess?” Solange asked, pulling up a chair to sit next to Agwe. An abscess, cold to the touch, was almost always present in Pott’s.
“No. I’ve checked him twice, and so far he’s negative for a cold abscess. That doesn’t mean it won’t develop, but Mr Bourg has been ill for a couple of weeks now, according to his wife, so it’s not likely to appear at this point.”
“That’s good,” Solange said, taking hold of Agwe Bourg’s hand. “Standing over a patient, looking down at him, is so impersonal. I like being on their level. It makes for a better rapport.” Gently, she gave the man’s hand a squeeze, then watched as he squeezed back. “Good muscle tone. Good reflexes. Do either of you have a stethoscope?”
Paul pulled one from his pocket and handed it to her. She listened to Agwe’s breath sounds for a moment, then handed the stethoscope back. “Clear lungs.” She looked at Agwe. “Do you have a cough?”
He shrugged to indicate he didn’t understand. So Solange repeated the question in Creole—the language spoken by most of the rurals. On Kijé, the languages were a mixed bag. Broken English, Creole, and, among the uppercrust, French.
“OK, no,” Agwe said.
“Do you think the TB might be going active?” Allain asked, totally captivated by Solange’s gentle bedside manner.
Paul noticed that the younger doctor had barely taken a breath as he watched Solange check Mr Bourg. It was such a subtle lesson she was teaching. One about eliminating the impersonal tone in medical practice and making the patient feel cared for. A chair at the side of the bed, a squeeze of the hand…these were such simple little things that mattered so much. With all the haste and hurry around his hospital, Paul thought about how often the simple things were overlooked, and he admired Solange for remembering. Somehow, she would always manage them no matter how rushed she was, and he admired that even more.
“His TB going active is a possibility,” Solange said. “It can do that, depending upon certain factors—more exposure to the active disease, other physical illnesses or weaknesses. But I think Mr Bourg is doing fine. Probably suffering from some kind of secondary infection outside Pott’s, if I’m not mistaken. Because when I took his hand, he shifted in the bed and moved his legs. Just a little, mind you, but I saw movement.” Her eyes crinkled a smile at Paul over the top of her mask. “You did, too, didn’t you?”
Paul nodded, his eyes smiling back. “So I think we’re all in agreement now that’s it’s probably not Pott’s disease, and Mr Bourg is one lucky man because of it. But we’ll still need some blood tests to rule it out.”
Solaina bent forward to speak to Agwe, to which he responded by pulling down his mask and giving her a great big grin, revealing a mouth full of rotten brown teeth. Friendly, but infected. And there it was. An uncomplicated thing now. “There, Doctors, is the source of our initial infection, I believe. Our patient here said he’s been pulling out his own teeth.”
Paul looked down at Solange over the top of his mask, and the instant their eyes met, the look they shared confirmed a diagnosis for Agwe Bourg. “Osteomyelitis,” they said at the same time.
“Told you it wasn’t quacking like a duck,” Allain chimed in. “And if it’s osteomyelitis, the pain’s probably so bad that Mr Bourg just quit moving to avoid it. So I guess he yanked his infected tooth and the infection spread.”
“When you don’t have a dentist, that’s what you do. And, personally, I’ve always hated the dentist,” Solange commented, shuddering. “But pulling your own teeth…I think I’d rather cut myself open and remove my own appendix, without anesthesia, over pulling out my teeth.”
“Well, I’m pretty good at removing an appendix, if you ever have a need,” Allain said, already bending over Agwe with a penlight and peering into his mouth. “And from the looks of things in here, I’d guess I’m about to get good with dental extractions, because we’ve got at least three potential sources for infection festering away right now.” Dental infections were often the cause of serious, even fatal, illnesses that resulted from harmful bacteria escaping into the bloodstream. When they lodged in the heart, which was common, it was called bacterial endocarditis, and out here, more often than not, it was fatal. And when they lodged in the bone, it was called osteomyelitis, and could be fatal if not treated, but if caught it was treatable. Today was Agwe Bourg’s lucky day. He was treatable.
“Allain’s the enthusiastic kind,” Paul commented. “He’ll take on anything.”
“Especially eight straight hours of sleep,” Allain called after them as Paul and Solange left the tiny room. “If anybody’s interested in giving them to me.”
“He’s a good doctor,” Paul said once Allain was out of earshot. “Young, a little unorthodox, enthusiastic, and great instincts. I’m glad Frère Léon found him.”
“Another one?”
Paul nodded. “Like I said, he’s a tricky devil.”
Solange laid her hand on Paul’s arm and gave him a gentle squeeze. “With or without Frère Léon, this is a nice hospital, Paul. If I weren’t already involved up in the mountains, I’d be honored to work here.”
“And I would be honored to have you work here.” He glanced down at her hand on his arm, and drew in a sharp breath. Another one of the simple things Solange did, and he could feel the sparks of it all the way down to his toes.
“We’re divided into several large wards, accommodating sixteen beds maximum in each one. Plus, as you’re noticing, we’ve got patients in the halls.” Bed after bed lining the walls. “With any luck, we’ll be starting a building project in a few months to add on two more patient wards and a children’s ward.”
Times like this, when he needed so much more, gave Paul the overwhelming urge to get back out there and find the support. “Right now we’re over the maximum capacity, and we’re beginning to feel it because, like the rest of the medical world, we’re short-staffed.”
“Did you anticipate this kind of need when you set up here?”
“I anticipated a few patients straggling in every day, and I’ll be the first one to admit that I was wrong.” He shook his head. “It’s frustrating at times, but we don’t turn anybody away.” Paul stepped aside to allow Solange her first good look into one of the men’s wards. “It’s not modern by any standards, but it works quite nicely,” he explained.
“Modern?” Solange exclaimed, stepping up to look through the glass in the door. “This is wonderful, Paul. Even my clinic in Miami wasn’t this nice.” Of course, Mauricio had cut corners every time he’d found one to cut, saving that money for his upscale move. Their upscale move. Only she hadn’t known it at the time. “And, believe me, if I could ever come anywhere close to something like this, I’d think I’d died and gone to heaven.”
It was a bare-essentials set-up. A bed, a bedside stand, a patient—sixteen of them lined up in two well-kept rows of eight each. There wasn’t much room in the ward, but it was tidy. “Thanks to Frère Léon?” she asked.
“In part, yes. He supplied the craftsmen to get it built. Locals who wanted a hospital nearby. He had an army of them, and it went up much like an Amish barn-raising. The men working, the women feeding the men, the children playing around the area.” He chuckled. “I think Frère Léon told them if they didn’t get it done quickly, Joanna and I might change our minds and leave.”
“The tricky devil,” Solange laughed.
“And you said you’re in an old mission chapel?”
Solange nodded. “Ayida and Keskeya—my nurses—and I actually live in the chapel, and the infirmary is in a brand-new building separate from it.” It was a nice, comfortable set-up and she loved it. “The whole compound was a cloister a century ago, but the monks moved to the other side of the mountains about seventy years ago to be closer to the major throughways.” She smiled, thinking about how glad she was they’d left the old compound behind. It was the perfect place, where several roads led in and out. The villagers were using them now to come to The Mission, as it was called, for clinic days, where medical services were offered at the infirmary instead of out in the villages. “How many people work here, at your hospital?” she asked.
“Right now I have three physicians, all specializing in infectious diseases, besides myself, although I don’t really count myself as a physician. And I have twice that many nurses and nurse aides. We also have a lab technician and an X-ray technician. Like I said, we’re short-staffed according to our patient load, but we make do.” He smiled uncomfortably. “Of course, we’re doing much better on staff than you are, aren’t we?”
A young woman dressed in khaki shorts and a T-shirt scurried to the bedside of an older man to change an IV bag, and Solange watched the interchange between nurse and patient. Pleasant, efficient. Paul had a nice concern here. “Actually, we’re quite satisfactory in numbers. I’m out a good bit of the time, and Ayida and Keskeya take care of the infirmary while I’m away. And if I need to be there as a doctor, I’m there. People don’t get all fussy and bothered over schedules and appointments out where we are, so it works out splendidly for us.”
Paul led Solange to a door marked “TB”, and they stood outside, looking in through the window. “Do you treat a lot of TB?” she asked.
“About half our patient beds are devoted to it. Not enough to call us a TB hospital, but enough that we keep busy with it. The wards I’m going to add will be much larger than our normal wards, and they’ll be specifically for people with TB. I’m actually going to build a separate building for it, so the patients won’t have to be quite so confined.
“But the good thing about our TB program is that we actually have good luck with the treatment and cure rate when the patients get to us in time, then continue to take their medicines for that interminably long year after diagnosis. Which many of them do, now that they know there’s help available. We try to dose them here in the mornings, if they’ll come here…It’s the easiest way to keep on top of things. And we do some education on TB symptoms, making it more likely that if people recognize the symptoms they’ll come to us in the early stages rather than later on. Care to join me inside?”
Paul strolled through the doorway into the ward, with Solange following. “One of the biggest problems we have is that so many of the people quit once their treatment is started and they feel better. We get a lot of recurrences, and every single one of the men in this ward fall into that category. They took their INH, felt better, stopped it, and now they’re back. Only most of them have some form of drug resistance going now, which is what usually happens when you stop treatment in mid-course. And the next time around TB is so much harder to treat.
“So to lessen our workload, we hunt our patients down when we can, just to make sure we don’t get them back in here in another few months in the condition most of these men are in.” He gestured to the men in the ward and most of them responded with a friendly wave.
“Sometimes the condition doesn’t recur, though,” Solange said. “Sometimes TB doesn’t come back.”
“Sometimes, but rarely. If we could keep them here the whole time…” He shrugged. “But you don’t treat TB that way any more.”
“Dr Paul!” a middle-aged woman shouted as she ran down the short hallway toward them. “She came in with the baby already on the way out. And it’s not waiting to get born, except the cord’s coming first.”
“What?” Paul snapped, spinning around to Gigon Giroir, one of his trained nurses.
“The baby is not waiting, but the cord is beatin’ it out. She’s prolapsing, Doctor, and it’s not looking good ’cos she’s having some hard, fast contractions.”
Paul and Solange exchanged knowing glances before they ran down the hall, following Gigon, who ran so fast she looked like a sprinter heading for the finish line. “Start an IV,” Paul shouted after her. “Get set up for a Caesarean section and go find Dr Mordecai.”
“Do you deliver babies often?” Solange called.
“No, they go to the village midwife if it’s a normal delivery. We just get the bad ones.”
Solange followed Paul into the small procedure room, where a very pregnant woman was moaning on the examination table. Gigon was already slipping an IV catheter into the mother-to-be, whispering soothing words…words that seemed to have some effect since the mother wasn’t screaming at the top of her lungs.
A nursing aide cracked the valve of a green oxygen cylinder to blow off any settling dust, then hooked rubber tubing to it in preparation of placing a mask over the patient’s face.
The initial hiss of the oxygen blast startled the patient, who struggled tried to sit up, but Solange stepped up to her side and laid a reassuring hand on her shoulder to keep her down while the aide fastened the mask over her face then scurried around the bed to pile pillows under the pregnant woman’s bottom. That made it easier to keep the umbilicus from tangling around the baby’s neck.
“Where’s Isabella?” Paul called to Gigon. Dr Isabella Mordecai was an experienced surgeon who had chosen to practice infectious disease medicine over surgery. “I’d much rather she did the surgery than me.”
“She’s got someone down there on the active ward, spittin’ up blood something awful,” Gigon said. “She’ll get here when she can. Dr Allain just got one of the patients ready to pull some teeth, and Dr Wally is in town, doing the follow-up on dosing this afternoon. So it’s up to you.” She glanced over at Solange. “Unless that one’s a doctor who can do it.”
Paul glanced over at Solange, too, as he wrapped a blood-pressure cuff around the expectant mother’s arm and started to pump the rubber bulb. “So, can you do a C-section?” he asked her. “Not that I’d put you in the position of doing it if you didn’t want to. But I’m not exactly a sterling example of a surgeon, and if you’d…” Instead of finishing, he stuck the stethoscope into his ears and inflated the blood-pressure cuff, then nodded seconds later as the hiss of deflating air showed the woman’s blood pressure to be normal.
“I can do it,” Solange said, tightening her mask. It had been a while since she’d done it in practice, but she’d had a whole year in which she’d studied up on procedures she might have gone a bit rusty on. C-sections were included in that. So she was ready. “Do you have some kind of anesthetic?”
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