A welcome reminder a long way from home
By Lesca Hadley, MD
On the second day of a spring break medical trip in the mountains of Guatemala, an 87-year-old patient led carefully by her great grandson’s wife entered the schoolroom where I was seeing patients with a UNTHSC medical student, a nursing student, and our Spanish translator. She couldn’t have had another wrinkle on her wizened face. She lived alone on the edge of her village near fields of corn. Everyday she walked her route, selling milk she got from her neighbor to the families in town.
She had delivered milk the previous day, but on this day, she was too weak to stand without help. She had a temperature of 99.5, and she felt hot. Her productive cough was audible. She trembled as our small interprofessional team began to examine her, gently raising her clothing. This was her first time to see a doctor.
She looked cachectic, obviously having lost a tremendous amount of weight, but now her appetite had declined further. During the visit, as her head hung low, she slowly told us through tears how all her other relatives had died. She was alone.
She had no abdominal or urinary complaints, her lungs were clear other than a few scattered rales, and she had no wounds. We had no available X-ray. Her conjunctiva seemed to indicate that she was not anemic and in our makeshift clinic, we had no other way to evaluate the components of her CBC.
Intramuscular ceftriaxone was our best available medication for probable pneumonia. Another nursing student who doubled as the pharmacist mixed the medicine into a syringe and then carefully injected it into her bony hip. The needle penetrated the skin like a sewing needle going through leather.
With consternation, the patient agreed that she felt too bad to cook and we thought she would be likely to fall on the rocky roads or in her small house in her condition. Usually, even in Guatemala, the recommendation would be a hospital admission. Treating an 87-year-old with pneumonia is risky, but so many adverse events could happen to this woman in a hospital.
She did not want to leave her home even to stay with her family, much less go to the hospital, and following much persuasion, she agreed to go with her great-grandson’s wife, the only family she had left. After warning her that her situation could worsen, I promised a home visit the next day.
After a long day of clinic on the following day, I gathered the ceftriaxone, a medical student, two nursing students, and our translator and set off to see our patient. For about 20 minutes, we followed a member of her family up a hill over a very rocky uneven road. We navigated around a hole in the road the size of a small car. When we thought we had crested the hill, we passed a mobile concession stand, turned left into a narrow alley, and continued to climb.
Upon arrival, we walked through the dimly lit house to where the patient was resting on the sofa. Her face lit up, lifting all the wrinkles skyward. As we sat on chairs surrounding her, she told us how much she had worried about us forgetting to come. She had only eaten a tortilla that day, but her caretaker was encouraging the liquids and still pressing her to eat. Her forehead was warm, but she felt better than the previous day. She again slightly retracted with each breath, but her cough was improved.
Amazingly she had walked alone to her home across town when she had grown bored during the afternoon. Her doting caregiver had only agreed to let her go when she promised to return for our visit. The family repeatedly told us how grateful they felt for the visit.
With permission, we took pictures of the patient and her family. When our patient saw herself in a photo, she put her hands on her head, exclaiming she should have fixed her hair. Finally, we ended the visit with the nursing students giving the antibiotic in the other hip.
Our team left the house feeling overjoyed with the incredible recovery of our patient. The family waved to us on the porch as we walked down the alley towards the road. On the way back, our translator found a tuk-tuk to give us a free ride, so we had six adults in a tiny tuk-tuk going down the same rocky road. Surprisingly all the tuk-tuk tires survived the trip.
I had told the patient we would return the following morning, but clinic was bustling. Lunch came at 3 p.m. when we finished. I left with six others in a truck bound for Guatemala City and the airport. Since I was going to the airport, I was unable to take my interprofessional team again. Instead, I took the same antibiotic in a syringe, along with enough oral antibiotics for ten days.
My patient and her caregiver were sitting on the porch, waiting for me. Immediately they began to express their thankfulness for the visit. The excited caregiver told me my patient had eaten at the table with the family. The patient felt afebrile and had no retractions when she talked quickly. She was walking more comfortably on her own. She showed noticeable improvement over the previous day.
Missing my team, I gave the injection, and I explained the oral antibiotics to the caregiver in my discharge directions. Both the patient and caregiver hugged and kissed me repeatedly. The caregiver then brought me a small Guatemalan purse made of handwoven Typica material as a gift. At that point, I could not stop the tears as they began to roll down my cheeks and face. Somehow all the pain and frustrations of the last several months seemed redeemed with her gift.
The patient told of how lonely she had felt at home by herself, not knowing her family, and now she had found family who truly cared for her. They prayed for God to bless me, and my patient told me to wear the purse across my body to keep it from falling off my shoulder. I wish I could have stayed longer in that small room with my patient surrounded by the green walls filled with pictures of her family.
Suddenly, I felt I had been caring for my grandmother again. Through my spry patient, I saw my grandmother’s sweet smile and heard her encouragement. She had a sound mind with a hearing deficit, just like my grandmother had at the same age. On this day through my patient, God reminded me of why I am here: To serve and protect those who cannot care for themselves.