18 September 2009

News in brief:
1. The Ecuadorian government chose not to renew the ten-year contract to allow the US Military to occupy the base in the city of Manta. A small ceremony was held at the site.
2. There were three scorpions in the house last night. One was very big. Bela valiantly took care of all three.

22 September 2009

An elderly woman came into the clinic last week complaining of feeling tired and having a hard time carrying the same amount of wood that she was used to carrying. She is a long-term patient of the clinic’s; she is being followed for high blood pressure, and for the past year has taken one blood pressure pill in the morning. After talking with her about her symptoms and her health in general, I took her blood pressure and examined her. Her blood pressure reading was high.

After I completed my exam, and talked with her some more, I stepped out of the room to read more about the blood pressure medicine that she was on, and to read more about hypertension in general and physical exam maneuvers that I should be sure to do. From the reading I learned that the blood pressure medicine that she takes works best when taken two times a day, instead of one. I decided that the best plan for her would be to add another dose of her medicine in the afternoon, so that she would take one blood pressure pill in the morning and one in the afternoon. Additionally, she had been taking a baby aspirin, so I gave her a month’s worth of that medicine as well. During our conversation she mentioned that she felt as though she was in a state of lack of vitamins, so I brought her a month’s worth of multivitamin to take once a day as well as the other pills.

I went back into the room to give her the medicines and explain how she would take them. After explaining, I asked her to repeat back what I had prescribed. It didn’t seem as though she understood completely the way in which I hoped she would take the medicine, so I described the plan again. Again I asked her to tell me how she would take them. We went back and forth for awhile, and finally she asked me to tell her exactly the times of day when she should take the medicine. I told her that she could take a blood pressure pill in the morning, with the vitamin, and another blood pressure pill with the aspirin in the evening. With that schedule it seemed that she and I both agreed on a medicine regimen. However, I was worried about her, and didn’t feel completely comfortable with our information exchange. Each bag of medicines contains written instructions with how to take pills. She cannot read. I had tried to draw a schedule for the medicines; I am no artist and schematics are born of a cultural context that she and I do not share. I asked her to return to the clinic in one week so that I could check her pressure again.
She arrived midway through the morning during the following week. She told me that she was still having the same symptoms that she had before. We talked some more about how her week had been, and her family, and then moved on to her medicines. She explained to me that she took her blood pressure pill in the morning, along with a vitamin, and then took the aspirin and the vitamin in the afternoon. I checked her blood pressure again. On this return visit it was still high, a little bit higher than the week before. We talked again about the way she was taking her medicine, and I repeated that I would like her to take two blood pressure pills a day, one in the morning and one in the afternoon. Again it seemed that I was not explaining myself well, for she did not seem to understand the way in which I was telling her to take her medicine.

At this point I excused myself, and went to talk to Etelvina, the health promoter who runs the clinic and is the primary care provider for an area of more than 2000 people. She has worked as a health promoter for over fifteen years, and is well loved and trusted by the community. I explained that I was having trouble explaining to the patient how I would like her to take the medicines, and asked if she would go in and talk with her.

Etelvina came out of the room ten minutes later with a smile on her face. We went into the pharmacy to talk, and she explained to me that she is definitely going to take two blood pressure pills from now on, one in the morning and one in the afternoon. “How could I have explained myself better?” I asked. “I really don’t think she understood what I was saying.”

Etelvina responded, “She understood you perfectly, but you didn’t leave enough room in the schedule for her vitamin. She wants to take the vitamin pill in the afternoon, and you didn’t leave a space for it.”

“Leave a space for it? I don’t understand!”

“She wants to take no more than two pills at a time, leaving room for an afternoon vitamin. To her, the vitamin is more important than the blood pressure pill, so she decided to drop the extra blood pressure pill you told her to take so that she could take the vitamin. I told her that we could allow her to take all of her medicines by moving the aspirin to the morning. From now on she will take one blood pressure pill with an aspirin in the morning, and the second blood pressure pill and the vitamin in the late afternoon.”

I went back into the room and talked with the patient some more about her medicine schedule. I repeated the schedule that she had discussed with Etelvina, and she told me that it was a much better way to take the medicine than I had told her before. I smiled and asked her to come back in four days to check on her symptoms and her blood pressure again. She returned in four days, and when I walked in to the room she announced that she was taking two blood pressure pills a day, one in the morning with the aspiring and one in the afternoon with the vitamin. Additionally, she pointed out, the vitamin had really improved her energy level and her health.

Thanks to Etelvina, the patient and I were able to align our priorities. However, I spent the evening after her second visit trying to replay in my mind the first conversation that we had had. I wonder whether I missed what she was telling me. When she first described how she felt, she told me that she believed her symptoms were from a lack of vitamins. I overlooked this statement, and pushed it even further back in my mind when I took her blood pressure. However, by overlooking what she had said I failed to realize that my treatment didn’t take into account her needs. She had done what she had thought was best and prioritized her medicines based on what she believed was causing her to feel the way she felt.