We left El Salvador in April, nearly two months ago. I count myself fortunate to have worked in Estancia. I count myself blessed to have gone there with Calla. I thought Calla was my Elizabeth Bennett, but I discovered she is so much more to me. I learned so much from her and am so proud of her.

I spent the first night away from Estancia crying. I cried because I was sad to leave. I cried because the people in estancia could not leave.

Now, two months later, I find myself back in Rochester and preparing for fourth year, as if I had never left. Despite the fact that my experience was the most significant and enlightening time of my life, my daily activities have a way of distancing this experience from myself.

When I think about all the different work I did, there is one common theme that saturated my whole experience. Poverty. The dehumanizing effect of poverty is like a stain that cannot be washed off, only ignored.

I was only able to spend 8 months in Estancia because I received a generous stipend. Helping others is one of the most truly satisfying and rewarding ways to spend time. It saddens me that the poor are generally excluded from this experience. When Calla and I left Estancia, we gave away the majority of our things to friends as presents.

We were also given goodbye gifts, usually a bag of beans. In addition to our gift of beans, people often apologized for how meager their gift was. I was so touched by these gifts because I knew how little our friends had to offer, but I was also saddened by the apology. Even though these people had given much more of themselves in their gifts of beans than I had with my used clothing, they were the ones who felt shame because of the stain of poverty.

I did not feel any “culture shock” as I returned to the wealth and excessiveness of America. I was struck by how successful the wealthy are at hiding poverty from every aspect of their life.

As a wealthy person living in Estancia, I was always aware that I had ten bucks in my pocket, while my neighbors made about three dollars a day for seven people. At the very least I was forced to feel uncomfortable, and it compelled me to do what I could to help them.

I went to med school to help people, but it took going to El Salvador to make me feel like I was. As a doctor, every patient is an opportunity to help someone. My lesson from Estancia is that if I am not helping the poor, then I do nothing to wash away the stink of poverty.

-- Bela

Photos

1. Sunset
2. His grandfather is kicking a soccer ball to him
3. Playing race cars
4. and 5. Neighbors
6. Making protein meal for malnutrition program (Siete Semillas--Seven Seeds)
7. Neighbors
8. Town corn-grinding mill, owned by women's coop
9. Carrying cornmeal to the mill
10. I can only make baby tortillas
11. Town band
12. Etelvina

Final Thoughts

Bela and I have returned back to the United States. We spent a total of eight months in Estancia, and the time flew by. Part of me cannot believe that we are already back home, and part of me feels like the time went too fast to even be real. It is almost as if we haven't even left yet.

Our last few weeks in Estancia were spent in a macroscopic version of a sign-out. Every volunteer from Doctors for Global Health becomes attached to specific patients, and these patients, over the years, have come to be known as "special patients." These patients typically have both complicated medical histories and difficult social circumstances, and it is a main job of volunteers to advocate for these patients both within the health system in El Salvador and in the local community. Leaving is particularly hard in terms of signing over the care of these patients. I think that I speak for both Bela and myself when I say that the goodbyes were emotional and difficult. Luckily, Juan Carlos and Etelvina are still tirelessly working in the clinic--seeing patients, providing psycho-social support, and accompanying patients to the hospital or to specialist appointments when they are able.

In addition to saying goodbye, many people wanted to share with us their stories from the war in El Salvador. I can only speculate about motivations for sharing with us during our departure. I imagine that it was easier for people to talk with us, knowing we were to be leaving for a period of time (although it is our promise to return to visit within the year). I also imagine that people feel a need to not be forgotten, as a story shared is a story that lives on. I also hope that Bela and I earned a level of trust over the time that we were there. We both believe that the community, after surviving the war, surviving extreme poverty, and working together to change the future, deserves a tremendous amount of respect. We tried to let people know that we respect them, respect their generosity towards us, and respect their incredible capabilities and talents.

However, the stories of the war were very difficult for me to listen to. People related incredible violence against themselves and their families. The histories were not related in a detached, emotionless way. Rather, it is apparent that the memories of the war are very clear, and very painful. Some things that were told were so awful that I had to try to calm my stomach in order not to vomit. Women endured rape. Children watched beheadings of their parents, and parents of their children. Hangings, shootings in the back of the head, torture of the elderly. War is not justice.

I had barely the amount of emotional strength needed to be able to listen to the stories. I am amazed and awed by the resiliency of the people of Estancia. To wake up every morning, to prepare food, to care for children, to farm, to endure day after day.

* * *

I also wanted to follow up on a few patients.

The man with anemia passed away two weeks ago. He was at home, comfortable according to his family, and surrounded by people who love him.

Following our trips to the hospital in December and January, he was able to be scheduled for an upper endoscopy, a procedure to look at the stomach to see if there is an ulcer or a cancer, in early February. The endoscopy was completely normal. Following the procedure I asked the gastroenterologist from San Miguel to please interview and examine the patient again, from scratch, as I was confused as to what could be his diagnosis. She spent about forty-five minutes with the patient, and then came out to speak with me, to clarify some parts of his history and share her thoughts.

She sat down to think. After awhile, she looked at me and said, “You know, I think he has kidney failure. It can look like so many other things, and would explain his severe anemia and mild congestive heart failure.” She agreed to admit him to the hospital in San Miguel to perform the necessary tests. After writing up a note and test recommendations, the physician had a long conversation with me about the clinical symptoms and signs of advanced kidney disease. As she talked, I thought about the patient, and all of things that I had assumed were not part of the main problem causing him to be so sick, and I reminded myself to read more about kidney failure.

Bela, Juan Carlos, and I spent the next month following up with tests, and accompanying the patient to outpatient appointments with the nephrologist in San Miguel. The trips were always difficult. Ramiro, the NGO director, would drive the patient and his oldest son (who was always at every appointment) up to the top of the hill and to Cacaopera, where we would catch a bus to Gotera. Once in Gotera, we would catch a bus to San Miguel, a trip of an hour and fifteen minutes. Once in San Miguel, we would take another bus from the terminal to the hospital, a trip of 20 minutes. At the end of the day we would make the trip in reverse, and the patient would be exhausted.

The nephrologist was a wonderful woman. She was very kind, and very respectful of the patient. On the day when she talked with the patient and his son about prognosis, she spent about forty minutes with us answering questions, and used simple language that the patient could understand. She explained at that visit that his options for treatment were limited to palliative care or dialysis. She encouraged the patient to have a family meeting to discuss options and goals. She made a follow-up appointment for three weeks later, and gave Bela and I her cell phone number, and told us to call if the family or we had any questions prior to that.

Before the leaving the office, the patient asked her, “Why did this happen.” The doctor pursed her lip, and said, “I’m sorry, I don’t know.” This answer did not satisfy the patient, and he repeated his question, and, after again receiving the same response, replied, “Well, you must have some ideas at least.” The doctor repeated that she didn’t know what had caused his kidney disease specifically, but she had seen a sharp increase in cases of kidney disease from the Morazán province. She explained that she was among a group of nephrologists who believe that it may have to do with the war. Morazán was heavily bombed during the war. In places like Estancia, bombs were dropped from airplanes almost daily for a number of years. A group in Mexico that studies environmental effects of war and conflict had tested some of the rivers in the area and found extraordinary levels of heavy metal contamination, and she explained that the lead levels were quite shocking. It is her concern that kidney failure might be an unrecognized long-term consequence of war. She then lowered her voice, “To me it is an injustice of the greatest magnitude.”

Following this discussion, there was a moving exchange between the patient, his son, and the nephrologist. The nephrologist displayed gratitude to the son for caring so well for his father, and to the patient for his service to the poor. The patient smiled. “I am poor. I am dirt poor. So these,” and he made a sweeping gesture in the direction of the waiting room, “are just my people. We look out for each other.”

We arrived back in Cacaopera after dark, long past the departure time of the latest bus in the evening. Ramiro came to pick us up, and we set up a time to come back and meet with the family. At the meeting, we tried to listen to everyone and answer questions. The patient seemed reluctant to attempt dialysis. His wife and son seemed to want him to try. We encouraged them to keep talking as a family. When we left, we told them that to us, whatever decision they came to as a family was the right decision. We explained that the patient had to choose what was best for him, and that it was Bela’s and my job to support that choice.

The follow-up appointment with the nephrologist occurred after Bela and I had returned to the States. We called the family the next day, and they told us that the patient had decided to not pursue dialysis. I asked to speak with the patient. I asked him how he was feeling. “Scared, but ok. I want to be at home, with my family.” I tried to validate his decision, but told him that he had the right to change his mind. “That’s funny,” he said, “The doctor said that too. She wants to see me in San Miguel every month to check up on me.”

Three weeks later, a few days before his next appointment, Victorino, the administrator of Campesinos para el Desarrollo Humano, left us a message in the afternoon. The patient had passed away in the morning. We called the family right away. Juan Carlos had arrived at the patient’s bedside in the morning, and had been very supportive of the family. The patient’s brothers had been notified and were traveling in from the coast. The son was stoic on the phone. “He knew it was going to happen. He called us together two days ago to say goodbye. He was very sleepy after that.” His wife was crying. “I miss him right now. I am so sad. But I am so glad that he is here with us, and that he didn’t die alone in a hospital.”

* * *

Following the death of the woman with congestive heart failure, Bela and I continued to visit the family. Her husband is a frail man, in his mid-eighties, and blind. He has an incredible sense of humor, and every time we visited had a new riddle or a joke for Bela.

The couple’s daughter lives in a neighborhood that is closer to Cacaopera, and, after a lot of family deliberation, it was determined that the man would go and live with them in their house.

He moved a week and a half before we left El Salvador. As we didn’t know that neighborhood very well, Abraham, the community health promoter for CDH, agreed to take us to the house. We had a wonderful visit with him and his family, and it broke my heart to say goodbye.

* * *

The woman who we took to the hospital with shortness of breath stayed there for a little over two weeks. When she was discharged, she went to stay at her daughter’s house in Cacaopera, to continue her medical treatment of antibiotic therapy for pneumonia (the tuberculosis tests that were done were negative). She returned to Estancia after that. Bela and I saw her about once a month, and ran into her grandchildren often. She is spry and funny, and very hard of hearing. Her grandchildren are very energetic and very polite, and it was always a pleasure to see them and chat.

* * *

What I learned:

Relationships matter. The relationship with Etelvina, the health promoter in charge of the clinic, was so important. I miss her terribly now that I am back in the States. She was fun to work with, and she is great mentor and teacher. She is in the community, of the community. She knows everyone, and keeps strict confidences. Seeing patients with her was enlightening and inspiring. I was able to sit with her in a visit from a woman with post-partum depression, in visits by farmers for physical therapy, do home visits with her, etc. etc. She is professional and kind, and is always trying to learn more about medicine and health care. Additionally, no patient care would be possible without the relationships. Working in such a tight-knit community made this so apparent.

Follow-up matters. I saw so many examples of this. We were lucky to be able to work closely with Abraham, the community health promoter. He was able to follow-up with many of our patients, and would report back how people were doing with medicines, or psycho-socially. If he thought someone was having a hard time with a certain treatment, or thought a certain treatment wasn’t working well, he would go with to see the patient again in their home, or bring the patient in to the clinic. Keeping in contact with the specialists in the public system was important as well, and helped our patients get the follow-up care they needed.

Palliative care matters. Over the course of our time in Estancia, three chronic patients passed away. All three patients wanted to die at home, and all three were able to do that. I believe that in two cases, the families were prepared for the deaths, and in once case, the family was less prepared. I think that Bela and I got better at having family discussions about care goals as the year went on. Etelvina is very good those conversations, and taught us a lot. Unfortunately, there is not much access to the kind of medical palliation available in the United States. I believe that better access to these treatments is necessary.

My happiness matters. Sometimes I needed a break. I love Estancia, and I love the work, but there were times when I was a little overwhelmed. I did the best work when I was happy. Our neighbors helped so much in this regard. After a long day, hanging out with them made me excited for the next day again. Swimming with them in the river on the weekends was relaxing, super fun, and helped me to not get burnt out. On particularly quiet days, Bela and I would take a break in the late afternoon to go for a walk, or to go buy freshly made semitas, a sweet cornbread, and sit and eat the bread and drink coffee while watching the sunset. I started running sometimes with a nine-year old (and extra-fast!) girl named Angelica. Sometimes her brothers or other neighborhood kids would come too, but she was always the fastest. And visiting families was always fun and a nice break from work. I think that we had a better experience because we made a little bit of time for ourselves.

Poverty matters. Poverty and illness go hand in hand. People who are poorer have less access to both curative and preventative health care. Poverty means no access to clean water, less environmental protection, less access to education, less nutritious food, more anemia, more malnutrition, more hunger (or, in the US, more obesity, but that is another story for another blog), more violence, etc. It is our duty to advocate for the poor, to change their situation. I don’t know the best way to do that, but I think all of us in medicine must try.

Coming home is harder than leaving. But this is something I learned before!

Thank you to my friends and family for supporting me during this year. Thank you to the University of Rochester and Doctors for Global Health for providing us with this opportunity. Thank you to the community of Estancia, for giving us the privilege and honor of working with you

--Calla

9 March 2010

An organization called Asociacion de Mujeres Salvadoreñas, contracted by the Ministry of Health, works in Estancia to provide preventative health care for women and children. AMS holds monthly medical brigades in CAIPES to perform well-child checks, and community health promoters visit pregnant women, women who have just given birth, and neonates. Silvia, Ramiro’s wife, is one of the community health promoters.

On the day following International Women’s Day, Silvia asked me to accompany her to see two women who had just returned home from giving birth in the hospital. Both were young women in their twenties, and both had delivered via cesarean section about a week ago. I agreed to go with her, help with the initial post-delivery evaluation, and remove their stitches from the surgery.

I met Silvia at her house early in the morning, and we began the hike to the two houses. She warned me early in the walk that we would be going straight up hill, and she was right. However, as we walked, she would turn back to point out various landmarks, especially sites that had been important during the war. She showed me the top of one mountain, where a giant massacre of civilians had taken place, and as we walked we talked about how much the community had suffered, but how much the community has also overcome.

We arrived at the first house. The mom was resting on the hammock with her baby girl, and Silvia and I worked together to examine them both. Part of Silvia’s work is to make sure that babies are gaining weight and are breastfeeding, and she evaluates the feeding of every newborn. She and I checked the C-section wound, and I took out the stitches. We talked to the mom for a while about feeding, emotions after giving birth for the first time, and things to expect over the next couple of days. Silvia made an appointment with the family; she would come back to visit in three days to check up.

The second house was a little more removed. The mom had given birth before, but this was her first C-section. Once again, we set about examining the mom and her new son. Both were doing well, and the wound was closed and without signs that made us worry about infection, and we took the stitches out. Once again, we spent time talking with the parents about what to expect. Silvia also talked with this family about obtaining a birth certificate, as this process had not yet been completed.

When we finished, Silvia walked me back to the road that leads to the clinic. She continued on, as she had three pregnant women to visit before the end of the day.

--Calla

14 February 2010

To culminate the fiestas of Cacaopera, the nearest town, a race was held on Sunday morning. Men were to run 10 kilometers, and the women 6, along the highway that runs to the northern part of the country. The highway cuts up and down the mountains, and cars often have difficulty making it up the last hill into town.

I decided to participate. The winner of the men and women each received $100, and the director of CDH, Ramiro, asked me to win and donate the money to buy more medicine. I explained that it was faulty logic to put his hopes on me, as I haven`t really run since arriving in the country. He said, "It doesn`t matter, just run as fast as you can!"

So on Sunday morning Bela and I woke up at 5 am, before the sun came up, and hiked 45 minutes straight up hill to get to the highway. We arrived, sweaty and tired, to wait for the start.

14 women participated; all were over a decade younger than me. It was a really hard run, straight down and straight up, alternating, the whole way. I ran with two high-school age girls, and when we arrived into town, I let them know that I would follow them in but they had to run fast. We all three finished together, which to me was an accomplishment given the terrain!

Bela was there waiting at the finish. He rode in the official race car of the mayor`s office. A girl from Estancia won, her second time in a row.

I feel really good about the race for two reasons. One, I finished, and was not too sore or tired at the end. Two, the race has been happening for many many years, but in August the government decided to allow women to participate. Therefore, this race was only the second that women have been able to run.

After the race, when the cash prize was being distributed, one of the workers in the mayors office came over to chat with me. He asked what sports women are allowed to play in the States. I explained, "All of them." He then borrowed the microphone from the mayor, who was distributing the prize, and said, "I think we have seen today that women can play sports. It is time to stop punishing our daughters if they go out to run, or play soccer, because one day they might be great athletes, like the two-time winner of the women`s race." I looked over, and the winner`s mom had a huge smile on her face.

--Calla

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