30 Nov 2012
One morning I was tasked with taking Isaías and his mother to a cardiologist’s private clinic. Isaías is almost 14 years old and has been a long-time student of the Guardería, the family support center.
The Pop Wuj Clinic does biannual well-child checks with the children of the Family Support Center. In March 2009 when Isaías was 10, one of our doctors at the time noticed that he had a grade II (on a scale of I to VI) systolic heart murmur.
Murmurs are a whooshing sound that a physician hears with a stethoscope. They are created when turbulent blood flow across an area of the heart or blood vessel produces noise. Pathologic murmurs, the kind you don’t want, are caused by structural problems that interfere with normal flow. Functional murmurs occur when physiologic conditions, normal conditions of the body, allow for the hearing of blood flow. This second type is common in children because they have more dynamic circulation and a thinner chest wall.
Isaías’ murmur seemed like a functional flow murmur to the doctor, who wrote in the chart that it should be followed for changes. The murmur continued as grade II/VI until 2012.
During a well-child check in September one of our current clinic doctors, Wilder, noted that Isaías’ murmur had changed to grade IV/VI. It had gotten much louder.
He was sent to the university/public hospital clinic to see Dr. Garrías, one of their cardiologists. After the doctor examined Isaías he said that the patient needed a special test: an echocardiogram. For some time we’d been hearing that the university’s cardiology equipment needs servicing. Isaías was thus told to go to Dr. Garrías’s separate private clinic where, as a university patient, he would receive a discounted rate for the echo.
Isaías and his mother Gloria met me promptly at 9am. Accompanying them on Gloria’s back was 10-month old Daniela, the youngest of Isaías’ five brothers and sisters. We walked through Xela and arrived at 9:30, quite early as the doctor wasn’t going to be working until 10.
The receptionist took our information and said the discounted rate shouldn’t be a problem.
We sat down and I began to ask Gloria questions about her family for the chronic patient info form. Gloria is 37 and works cleaning houses in Xela while raising five of her six children. Her eldest is married and has a child of her own. Her other children are ages 17, 13 (Isaías), 11, 10, and 10 months. The baby Daniela has a different father from the rest. Isaías is an attentive older brother and dotes on her.
10am came and went. Then 10:30. Then 10:45.
I asked about Isaías’ father. He “found a different woman” and no longer lives with the family. However, according to Gloria, he continues to be a source of financial and emotional support for the children. He lives in the same town and sees them frequently. As we were waiting Gloria’s cell phone kept ringing because Isaías’ father was anxious to know the results of the echo.
At 11am I lost my patience and asked the receptionist if the doctor was on his way.
“Yes. He’ll be here in un ratito.”
Un rato or its diminutive un ratito are the worst things to hear when you’re waiting. “A while” and “a little while” respectively, they could mean anything from a few minutes to A WHILE.
Dr. Garrías arrived at 11:30 and to his credit immediately began to see to Isaías. However he did not offer an apology for his tardiness, which upset me. This family had been on a bus for 30 minutes then walked another 30 to see him. And they could have come from much father.
He finished the echo and instructed us to wait outside.
After a few minutes the receptionist called me to her desk. She handed me a large brown envelope and told me the cost of the visit. I was incredulous.
“Doesn’t the doctor want to talk with us?” I asked.
“La cosa es que this visit just covers the test. You should take the results back to the doctor who originally referred you.”
My head almost exploded. I felt this was the height of discourtesy. As far as I’ve seen the consulted physician always goes over the results of the test with the patient. And he’s the cardiologist! This was a specialty cardiology test.
I wondered if the story would have been different if we were paying full price for the visit.
Isaías, Gloria, Daniela, and I walked back to Pop Wuj. Luckily Wilder was in attendance at clinic. I approached him while he was in between patients to give him the echo report. When I told him that Dr. Garrías did not go over the results with us, he was as disbelieving as I had been.
Wilder took out the report and we looked at it together.
“Mild insufficiency of the tricuspid valve.” The tricuspid is a gateway between two chambers of the heart, the right atrium and right ventricle. When the ventricle contracts to squeeze blood into the vessels of the lungs, the tricuspid is supposed to seal shut. Valvular insufficiency means that the valve does not completely seal. Backflow of blood occurs, accounting for Isaías’ murmur.
“Mild pulmonary artery hypertension.” Now that’s confusing. In the circuit of the heart the pulmonary artery comes after the tricuspid valve. Backflow of blood should initially cause problems earlier in the circuit, not after.
“How would you account for this, Nicki?”
“Um. I can’t.”
“Neither can I.”
Wilder took a picture of the report with his iPad. He then called in Isaías and Gloria. Gloria only wanted to be reassured that it was nothing serious. Wilder told them that there was nothing to worry about now, but there could be in the future if we leave Isaías condition alone for too long.
“I’m going to look into things a bit more. I’ll have Pop Wuj call you when I have more information.”
We bade the family goodbye. As Wilder closed the door he told me that he was going to show the report to some friends. Frowning, he said,
“I really wish the cardiologist had talked with you.”