28 January 2010

There is a patient who has been coming to the clinic for about a year with rheumatoid arthritis, a nasty painful disease requiring very toxic medications to control its progression. To properly treat this disease, the patient needs to see a rheumatologist, a specialist that can only be found in San Miguel, about a four hour journey from the clinic. The patient had last seen the rheumatologist in December. At that visit, the doctor told him to come back in a month with some lab studies and gave him medicine only for one month. The problem came when the patient tried to make the appointment with the nurse. She said the earliest he could get in with the doctor would be in July and there was nothing that could be done.

A month later when the patient was without medication and his pain was increasing he came into our clinic. Luckily we had some pills that could tide him over for the moment, but he still needed to get back in with the rheumatologist. I decided to call the rheumatologist just in case his schedule had opened up. He was super friendly and said he would make space for the patient the following Tuesday, we just had to get there by nine in the morning.

Where we live, it is impossible to arrive to San Miguel before ten in the morning. As I explained the situation to the patient, he promptly invited me to stay at his house in Cacaopera, which is closer to the hospital. It was a perfect plan.
I left the clinic the following Monday afternoon to catch the final bus to Cacaopera. We met in front of the town’s equivalent to a grocery store and walked to his house. His family was incredibly gracious and hospitable to me, and it meant a lot to me. We spent the evening eating fried fish and talking about life in El Salvador during the civil war.

A neighbor walked by while we were chatting out in front of his house. She heard there was a health care worker here and had a question. Her 7 year-old son had a painful ear that had been draining blood for about 2 months. She wondered if I could take a look at it. I happily agreed, but I couldn’t do much without my otoscope to look inside ears. I told her I would be back on Wednesday and would make sure to bring my equipment to properly assess his ear.

I recently read the book, Mountains Beyond Mountains, by Tracy Kidder. It is about Paul Farmer, a doctor that works in Haiti. He often walks miles to see a patient. In the book he remarked that when he goes to see one patient and happens to come across another, he feels like his visit was a “good cast”. For some reason I really like this fishing metaphor. It reminds of reading the New Testament in college, where Jesus called himself a fisher of men. While I have no religious inclinations, I always liked this idea. Anyway, when I saw this boy I felt like my visit had been a good cast because I had the opportunity to help two people when I had only anticipated one. I ended up coming back two days later and removed a ball of dirt about the size of a jelly bean from his ear, and I also gave him some antibiotics. I recently went back to the house. The kid was at school, but his mom told me that the ear was no longer bleeding and he was without pain. A success.

But getting back the original patient, we woke up the next morning at 4:30 to catch the 5 o’clock bus to San Miguel. The doctor was great and saw the patient with minimal delay. We were able to secure four months of medication for the patient and got him a follow-up appointment for four months as well. I got back to clinic Tuesday evening. I was exhausted but satisfied.

--Bela

29 January 2010

On Wednesday, 27 January 2010, the patient with heart failure passed away. She was at home, surrounded by friends and family. She died at five in the morning, and her family prepared her body for burial, which took place on Thursday.

She died 22 days after we met. I hope that she spent her last few weeks more comfortable based on our treatment. I think that she did, as she seemed to be drowning when I met her. She spent the last week of her life saying goodbye. Her extended family all came to visit, and members of the community held numerous ad hoc church services in her home. I visited her 10 times over the 22 days, and in that time got to talk with her, her husband, and her daughter a lot. She and her husband were married for 65 years. Additionally, in the last week of her life, her oldest great-grandson got married. She was too sick to attend the wedding, but the bride and groom came to the house after the ceremony, and brought the rice that had been served to the guests. The wedding rice was the last real food that the patient ate, and her evaluation was that it was “bien buena, un arroz tan rico como nunca he comida.”

--Calla

28 January 2010

Bela and I have been doing a lot of home visits. Additionally, we gave two charlas over the past month. One was about first response for burns, and the second was about hepatitis. Etelvina chose the topic of hepatitis because we identified 6 children in one neighborhood with symptoms of hepatitis A, and got them linked up with the Ministry of Health System. Here are a few photos:

--Calla

25 January 2010

Last Thursday, Bela and I embarked on what seems to be a Sisyphean task: we are attempting, per the Hospital in Gotera´s medical team´s request, to get a very anemic man transfused with two to three units of O negative blood.

In early December, Juan Carlos (the recent graduate from medical school, who just last week started working full time at the clinic to fulfill his Social Year requirements to begin practice) came to find Bela and me on a Saturday morning. He explained that his mother, a local community health promoter, had been at the patient´s house earlier in the week. Juan Carlos´s mother Silvia was very concerned, and so had told the man to come in. We waited and waited, and at two-thirty in the afternoon Juan Carlos began the trip back to San Miguel, the closest big city and the site of a course for recent graduates on the administrative duties for one´s Social Year.

Two days later, Ramiro came to talk to me about the patient. He drew me a quick map to direct me to the patient´s house, but Israel, the health promoter in training, volunteered to accompany me. We talked with Etelvina, who knew a little bit about the man´s history, before we started on our way.

It was, as most visits are, a long walk uphill to get to the house. We entered, and were greeted by a jubilant but thin and tired looking man. He was pleasant, and had a slow drawn-out way of telling stories and answering questions. He had had a long history of high blood pressure and gastritis, but over the last six months had begun to feel very bad. He was tired all the time, and was short of breath walking even short distances. His appetite was very poor, and he felt uncomfortable and burped a lot after eating even a little bit. Sometimes he had dark, tarry stools, and once had vomited blood. I examined him, and was surprised by his pallor. He seemed to be working hard to talk to me, but maintained his friendly demeanor throughout.
Israel and I came back to the clinic in time for the weekly staff meeting of CDH, the NGO. Afterwards, I talked with Ramiro about the visit, who suggested that I call Dr. Garcia, the director of the nearest Ministry of Health Clinic, and a constant source of advice and support for the clinic in Estancia. Dr. Garcia and I discussed the case, and he recommended that we take the patient to the hospital for more evaluation and possible blood transfusion.

Israel, Bela, and I took the patient to the hospital the next morning. His admission hematocrit was very, very low, and he stayed in the hospital for eight days. I visited him on two separate occasions during the admission to talk with his physicians and see how he was doing. Part of the reason that he stayed so long was the lack of compatible blood in the hospital´s blood bank, and a lack of equipment at the hospital to evaluate the cause of his anemia. He was discharged, with a date in another city for an endoscopy, which is a way to take a look inside the stomach to try to figure out whether something is bleeding and therefore causing anemia, and told to look for blood donors within his family who might be of the same blood type.

He went to the endoscopy appointment on the scheduled date, after having not eaten since the night before and traveling for about three hours to get there. The endoscopy machine was broken, and a repeat appointment was made for him in May, when there was the possibility of fixing the machine. He returned to Estancia, frustrated.

However, he was determined to follow the doctor´s orders for a blood transfusion. Some members of his family live in another city, on the Pacific Coast. We arranged with Ramiro to transport the patient to the hospital, and for the patient´s brothers to leave at three in the morning on the same day to meet us. Bela and I were introduced to the family outside of the hospital gates, and we went inside en masse to begin the preliminary testing for the potential donors.

None of the three brothers, nor the patient´s son, had the same blood type. Ten other donors were present that day to donate to various inpatients, and none of them had the same type either. There was no O negative blood in storage. Desperate, I asked the hospital´s social worker and director of the medicine residency program to meet quickly with me, to try to figure out a plan. We called the Red Cross in the capital. We called the public hospitals in both San Miguel and San Salvador. We tried to admit the patient directly to the hospital in San Salvador for more evaluation, but were not able to do that as the referral site for the Gotera Hospital is San Miguel and not San Salvador. We left the hospital in the afternoon, frustrated.

The public system is fraught with a dearth of resources, both in terms of medicines and machinery. Additionally, the people who work within the public system are seen by many as an addition to the problems that the poor suffer. However, in this case I saw many dedicated staff members, in the laboratory, the social work office, the resident room, and in the emergency room, trying to do their best. They are working in difficult circumstances. I believe that more attention on a macro-level is needed to resolve the resource problems within the public system.

--Calla

We use the big grey thing to sterilize equipment.

13 January 2010

Last Tuesday, a woman came to the clinic to talk about another woman, homebound, who was short of breath. Etelvina knew the patient, an 85 year old with a history of chronic respiratory infections. Etelvina asked me to accompany her up the mountain to see the patient.

After forty minutes of hiking uphill, we arrived. The woman had had a few days of fever and cough. The fever was gone, but she was still coughing. She was breathing fast, but did not want to go anywhere—not to the clinic, not to the hospital, and stated that she would take any medicine just so long as she could take it at home. Her blood pressure and pulse were ok, but her lungs sounded bad. Three other people in the house had coughs and colds, and so we decided to treat her for pneumonia and visit her again.

The next morning, another family member came to the clinic. “She has bad diarrhea,” the woman explained, “and we would like you to give her this medicine.” She pulled out a scrap of paper on which the word METRONIDAZOLE was printed in neat capitol letters. “We have heard that it is a good medicine for diarrhea.”

I was confused. The patient had explained to us the day before that she had had a few loose stools when she had the fever, but that it had gone away. I was also surprised that the family would be so concerned about diarrhea, when I had found her difficulty breathing much for troubling. I decided that my confusion would be better allayed with a visit to her home than by giving out a medicine I did not think would help or that might even be harmful. I sent the woman back to the house, and told her I would meet her there in one hour.

I went to get Etelvina. She was seeing a child with diarrhea. Additionally, another child who she had sent to the hospital a week before would be coming in for follow-up of a bad burn. She therefore asked Bela to go with me.

As we hiked up the mountain, I told Bela the story and my confusion in the morning. I was afraid that I had missed something. For modesty’s sake, as she lived in a one-room cane house that had been filled with people, I had not performed a thorough physical exam. The last part of the hike is rocky and steep, and as we ascended I told myself I would do better.

We walked in to the house, and it was clear that things had changed from the day before. The house was again filled with people, but there was a tension and anxiety that had not been present. The patient was sitting in the hammock, like the prior afternoon, but this time was being supported by four woman. She was breathing fast, but additionally made a course grunting noise with each breath. She seemed to be in severe distress.

I looked at Bela, and it was clear that he agreed—the woman needed to go the hospital. I explained our concerns, and the desire for her to let us take her. “No, I will not go,” she responded between grunts. “This is my home; this is my family. If I am to die tonight, then let it be here.”

I looked pleadingly at the family. “I am very concerned that she might die if we do not get help.”

“She has always told us that she would not want to go to the hospital. You may treat her here, but please respect her decision,” I was told firmly by her daughter, whom I had met the day before.

Her husband, a kind man who is completely blind, was sitting in a hammock behind me. He reached out for my shoulder. “We are always together. Please do not separate us.”

I was sitting in front of the patient, watching her watching me. Finally, she forcefully grunted, “I will not go.”

Bela put his hand on my shoulder. I told the family, “If this is your decision, then we have to respect it. We will do whatever we can here.”

“Thank you,” stated the patient.

We set about examining her. I was more thorough and deliberate than I had been the day before. And yes, I had missed something. Her legs were swollen and edematous. “And the diarrhea?” I asked.

“No, I don’t really have that,” replied the patient.

“She had one soft stool last night,” explained the woman who had come to the clinic.

Bela turned to me, “I think she is in heart failure.”

“Yes, I think you are right.”

I told the family that we needed to get some help, by calling doctors that could help guide her treatment. The family agreed, and I called my father. I presented the patient and we talked about a plan. We decided that a medicine called a diuretic, a type of medicine that can help get rid of extra water, could help her be more comfortable and help her breath better. Part of what happens in heart failure is that the lungs can fill with fluid, making a person feel as though they are drowning and cannot get enough air. Getting some of the fluid out of the body can help to relieve that.

We called the clinic and talked with Etelvina and Neal, the other medical student. Neal offered to run to the bottom of the mountain from the clinic with the medicine. Bela scrambled down to meet him, and I stayed with the patient and her family.

She was getting agitated, standing up, sitting back down. A granddaughter yelled out to me, “Please, just give her a shot of vitamins!” I explained that we did not have vitamin shots at the clinic. At my response, the patient heaved, “Get someone here who can pray for me!”

“Can you read?” another family member asked me.

“Yes, I can,” I responded.

People searched the house and the two neighboring ones for a prayer book, but could not find one. Bela arrived shortly thereafter with the medicine, and behind him came of the local pre-kindergarden teachers, book in hand. The patient took the medicine, and the family gathered around her. The group began to pray. After the prayer, all was quiet except for the sounds of the patient’s grunting breaths. All of a sudden, her husband cried out, “Oohh, my wonderful wife has died!”

“No, no, she is here.”

“Then we must sing.” He began to sing and sob, holding his hands out towards his wife. The family followed suit. I was standing at the edge of the group. I felt so helpless that tears welled up in my eyes and began to roll down my cheeks. A small great-grandchild saw me, walked over, and held onto the leg of my pants.

We stayed at the house for five hours, and as the sun began to set the patient began to urinate. I tried to be as hopeful and yet as realistic as I could. The patient was still in distress, and so I explained that I did not know if she would survive the night. I told that I would arrive in the morning.

As we crawled down the mountain, many people from the community went up. “Is she dying?” I was asked again and again.

“I don’t know,” is all I could respond.

That night I had a talk with Ramiro, the director of the local NGO and himself a health promotor. He assured me that we had done the right thing by not forcing her to go to the hospital against her wishes. I explained that I was worried and he responded that she was family, with the whole community by her side.

For the next two mornings, I woke up early and hiked the mountain to her house as the sun rose. She seemed to be unchanging, but she survived each night. I would examine her and call my dad for help with medicine dosing.

On Friday morning, she seemed ready to talk. Her daughter, exhausted from keeping vigil many nights in a row, brought over a plastic chair for me and laid down next to her mother in the hammock. The patient’s granddaughter brought us each a cup of a drink called atol, made of corn meal and flavored with cacao. We talked for a long time about the patient and her husband, about the ways that making tortillas had changed over the years, and about the community, past and present. I took leave when the sun had completely risen to return to the clinic.

As I walked out of the house, I felt overwhelmed and uncertain. Members of the community had seen a dark bird flying over the valley on Thursday, the symbol of death. No one hesitated to remind me on Thursday afternoon that the patient would not wake up on Friday morning. I had been afraid as I walked up the hill on Friday morning. I was also surprised to find the patient so conversant.

On Saturday, Bela returned to the house with me. We started a medicine that is usually used for blood pressure control, but that can also be used to protect the heart in a patient with heart failure.

On Monday, the patient was lying down in the hammock when we arrived. She was not grunting, and was breathing at a comfortable rate. Her daughter appeared more well-rested than she had been since I had met her. We examined the patient, and she seemed dryer—her lungs did not sound wet anymore and her leg swelling had disappeared. I called my dad again and interrupted a meeting between him and a few other physicians, and we able to talk about how best to proceed.

I still do not know what will happen. Her condition is delicate. However, I think that she is much more comfortable now. She has been able to talk with her family and be near her husband. I also do not know why she had heart failure to begin with. I have a few ideas, but no way to test them.

However, I feel very privileged to have been able to work with the patient and her family. I will continue to visit. They are teaching me about strength, about family, and about non-abandonment.

--Calla

12 January 2010

After a two-week hiatus in the States, Calla and I returned to El Salvador. We spent two days walking around the capital before traveling home to Estancia. It was great to be back. The only inconvenience was a lack of electricity in the clinic and the house. The clinic normally runs off of batteries that are charged by solar panels. The batteries died about a week before we left in December. They typically last 5 years and ours are now 7 years old. Normally, the lack of light is no more than a mere annoyance that requires us to cook by candlelight. Our first night back was a little different.

Within 30 minutes of arriving to the clinic to cook our dinner, we got a phone call. A family that lives about 20 minutes from the clinic was calling to see if they could bring their 7 year-old girl to the clinic because she had fallen and cut her face. We told them we were already at the clinic and were waiting for them. Our relaxing return home would have to wait because there was work to be done.

The girl arrived shortly. Two hours ago she had fallen and sliced her face open on a brick. She had a 7 cm laceration over her left eye. The cut was pretty deep, and I think that we were all uncomfortable. Luckily the cut did not involve her eye. If she had been in the States, a plastic surgeon would have been there to sew her up. But out here there was only us, three medical students in a clinic without electricity.

Since I have the most interest and experience in all things surgical, I was elected to fix her face. It was a surreal experience. That night I put seven stitches in this girl’s face only with the light of a single candle.

I told the girl to come back in four days to have the stitches removed. The whole week I was preoccupied with her wound. It was so deep and so close to her eye that bad things could happen. Four days later she returned to the clinic. Her wound looked fantastic! It was fully closed with minimal scarring and her eye was completely unaffected. I feel lucky that everything worked out, but it was yet another potent reminder of how tenuous our position is here as medical students working in an area without doctors.


--Bela