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