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.