This past Tuesday (6 days ago) we went to a local town on the lake for outreach clinic. Towards the end of the clinic Craig asked if I’d go see a few home bound patients that people were saying needed attention. So I went with Amanda, a first year medical student, and Odelia, a Guatemalan who works with us as an interpreter (Spanish to the local Mayan dialects). We go to this ladies’ house, which is about 10 feet by 8 feet and contains three things: a “patate” (basically a wood cot with a blanket on top), a tiny fire pit in the corner (no chimney or other ventilation), and the patient lying on the patate. This is how many people in this region live. She is a single parent of three children, none of whom work. They have no source of income.
She was in a horrible state; the worst I’ve seen in medical school (or any other time). The complaint that filtered through the grape vine to us at the clinic was “diabetes” and she certainly had that. We checked her blood glucose on Tuesday and it was 537. But there was a lot more going on. Apparently she had not gotten out of bed for the last 3 months and during that time had been eating just one cup of atol each day. Atol is a corn mush drink that many people drink here. She had been having chills, night sweats, and had lost a huge amount of weight over the preceding months. I’ve never seen anyone so emaciated; she was literally just skin and bone. On exam she had a 10x10 inch abdominal mass – not good. She was essentially immobile. We discussed the situation with Craig back at the clinic and decided to return the next day with IV fluid, palliation meds, and some other meds and equipment. She was insistent that she did not want to go to the hospital even though in our estimation she desperately needed it.
The next day we returned. This time Peyton and Craig came as well. What we found was appalling. Not in a derogatory sense, but in a “how could things have gotten to this point” sense. There were a few things I had neglected to investigate on exam the first day due to her extreme pain with any kind of manipulation. But when we returned we wanted to check for a few other things. In the process of doing so we discovered some shocking things, which prompted us to urge her and her family to allow us to transport her to the hospital.
After 10 minutes of discussion they agreed to go to the hospital. So Peyton and I got on each end of her, carefully lifted her on her blanket and were half way out the door when a lady runs in off the street yelling that we can’t take her and to put her down immediately. (This is all in Qachiquel, the local mayan language). So we of course put her down. Nohemi and Leti (our two interpreters) have a 10-15 minute discussion with this lady, who I think was a relative of the patient’s, and finally convince her that she needs hospital care. So Peyton and I again pick her up and start moving toward the waiting stretcher, when in runs a man off the street saying the same thing! “Put her down, she’s my sister and you can’t take her anywhere!” What the hell, people? We’ve got to go. The ambulance isn’t going to wait all day! So another 10-15 minute Qachiquel discussion ensues and Nohemi and Leti convince him that his sister does really need to go. So finally we get her out to the stretcher and into the ambulance.
It was Peyton’s and my job to ride with her in the back of the ambulance to the hospital. Sounds fun for two medical students. Turns out this was probably the most miserable hour and half of medical school so far. Even though I’m not going to go into the details of this patient’s condition, I will say that the resulting smell permeating the ambulance was unbelievable. Luckily the ambulance had two small windows which we could open to get some fresh air, but this just barely tempered the odor. Then, about half way through the trip the patient stirs a bit and motions to one of the two open windows. We don’t speak the same language obviously, but I got the idea that she wanted it closed. Crap. Well, we closed it for her and there went our ventilation. The horrible smell was making us incredibly nauseous, but what made things even worse was the driving. Now, not all of it was the fault of the driver. The road up from the lake to the Pan-American highway is very windy and hilly, with a million switchbacks. And the road back down to the hospital from the Pan-American highway is the same way. So there was reason to get motion-sick. But what our driver failed to realize (and this was our fault; we should have explained things) was that this was a completely non-urgent transport. There was no emergency here. The patient had been in this state for months. What we needed was a nice casual transport to the hospital. Instead we got a sirens blazing, weaving in and out of traffic, peeling out around the switchbacks experience that nearly put Peyton and me over the top. By about the half way point we were as green as could be and concentrating all our energy on keeping our GI contents within the GI tract. I have a new respect for EMTs and paramedics. They have a tough job. At one point the patient was being very still with her eyes closed and we decided it was reasonable to check and see if she were still alive. So we searched for a pulse. We couldn’t find anything, not even a carotid! Luckily, we stopped shortly after this and with the ambulance still we could easily tell that she had great peripheral pulses. I can’t imagine how hard it must be to take a full set of vitals, start IVs and all the rest in a speeding ambulance. Way to go paramedics.
Anyhow, we eventually made it to the hospital and delivered the patient to the ER. We explained things to the nurses and waited about an hour until we could talk with the doctor on staff. After explaining the situation to him, we left. It was dark and we had to find our way back to Santa Cruz. Thankfully, we didn’t have to wait long for a bus down to Panajachel, and we made it to the docks in time to catch the last lancha back to Santa Cruz. It was a long day, but overall I suppose a good experience. I really hope this lady does all right, but my suspicion is that she is not going to do well at all.
What happened here brings a few important points.
People here in Guatemala, especially the folks in the small villages who still speak the local Mayan dialect, have a very different view of hospitals than we in North America do. Our back and forth with everyone about whether this patient was going to the hospital or not seemed a little ridiculous at the time, given the gravity of her condition, but it represents a very common attitude. That is, many people here do not want to go to the hospital under any circumstances, no matter the seriousness of the situation. And they have good reasons. Often the hospitals provide sub-par care and the patients are looked down upon as second class citizens. Most of the time, no one at the hospital speaks their language (and they don't speak Spanish). And to top it off, most of the hospitals won't allow families to visit at all. So the experience is awful. It's lonely. They are frightened in part because they don't understand what's going on - indeed, it would be hard to understand even if everyone involved spoke the same language, but you can imagine how hard it must be when you don't speak the language of the people taking care of you! Because people resist hospitals so much, and the care at the hospitals isn't so great, people end up holding out as long as they can - until their conditions are very severe, before going to the hospital. Thus, people have the attitude that hospitals are places where people go to die - and that's it. So I can understand why this patient and her family put up such resistance to the idea of going to the hospital. It's a tough problem.
What happened here brings a few important points.
People here in Guatemala, especially the folks in the small villages who still speak the local Mayan dialect, have a very different view of hospitals than we in North America do. Our back and forth with everyone about whether this patient was going to the hospital or not seemed a little ridiculous at the time, given the gravity of her condition, but it represents a very common attitude. That is, many people here do not want to go to the hospital under any circumstances, no matter the seriousness of the situation. And they have good reasons. Often the hospitals provide sub-par care and the patients are looked down upon as second class citizens. Most of the time, no one at the hospital speaks their language (and they don't speak Spanish). And to top it off, most of the hospitals won't allow families to visit at all. So the experience is awful. It's lonely. They are frightened in part because they don't understand what's going on - indeed, it would be hard to understand even if everyone involved spoke the same language, but you can imagine how hard it must be when you don't speak the language of the people taking care of you! Because people resist hospitals so much, and the care at the hospitals isn't so great, people end up holding out as long as they can - until their conditions are very severe, before going to the hospital. Thus, people have the attitude that hospitals are places where people go to die - and that's it. So I can understand why this patient and her family put up such resistance to the idea of going to the hospital. It's a tough problem.
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