12 Mar 2013
Concepción was a 5-month old girl whom I met on the second day of her hospital stay. Her parents had brought her in because of trouble breathing and a cough. When Alexis, our pediatrician, checked her oxygen saturation it was below 80%. This is bad, especially in a young child that needs good oxygenation for proper brain development. Normal saturation in someone with healthy lungs is 97% or more.
Alexis diagnosed Concepción with bronchiolitis and admitted her to the hospital. Bronchiolitis is a common illness that affects children less than two years of age. Often it is caused by respiratory syncytial virus, leading to inflammation of the bronchioles or the small passages. Treatment is supportive. The most important thing is to keep the child’s oxygenation level up with supplemental oxygen administration.
In the early afternoon Concepción’s parents approached me. Their daughter seemed much improved to them and they wanted to go home. I went to Cathy, the doctor that I was on call with. We turned off Concepción’s supplemental oxygen and checked her saturation. It fell to 85%. Not good enough.
“Los pasajes a sus pulmones todavía están inflamadas.” The passageways to her lungs are still inflamed. “Her body won’t get enough oxygen without the extra she’s getting here. She has to stay until she no longer needs extra oxygen.”
“But her cough is gone. And she’s breathing much better.”
They didn’t get it.
I’d forgotten how complex the body can be. The idea of giving someone a higher percentage of oxygen (the air we breathe is 21% O2) so that, through their ill lungs, their body will still receive the amount that it needs – the amount that healthy lungs would pull out of the air – is a difficult one. And it can be a distinctly foreign one to someone from a different system of education and a different way of life.
We were struggling to explain, not getting anywhere. Finally, we asked the family to speak with our social worker. Once they learned that sliding scale payment system was available to them, based on their income, they agreed to stay.
The next morning at signout, the change-of-shift meeting where healthcare workers hand over their patients, Cathy and I expressed our frustration. We didn’t understand how parents could still want to remove their child from the hospital when her doctors are clearly telling them it is dangerous.
Nearing the end of his one-and-a-half-year stint with the hospitalito, Andy had much more experience with the patient population than we. He chimed in with some of the most important words of healthcare wisdom I’ve heard.
“It’s because their concern is not your concern.”
I think I actually stopped breathing for a second, so deep was their impact on me.
“They’re concerned about a cough. And about paying. Where you’re concerned about a saturation of 80%.”
He went on, bringing up a related topic with, “It’s the same when we try to get patients to go to Sololá.”
El Hospital Nacional de Sololá is our hospital of reference. It is where we send patients whose conditions our small hospital is not equipped to handle, such as surgical emergencies (we do not have a surgeon at all times, and only do elective surgeries).
Patients and their families are very resistant to being sent. A patient with an acute abdomen, doubled over with severe abdominal pain, was refusing to go and his family was agreeing with him. “No doc. *groan* I’m fine. *groan* I don’t need to go.”
I wanted to tell his family, “If you thought he was sick enough to bring him here, why won’t you take him a hospital with more resources??”
Andy had good insight on this phenomenon too. “You’re concerned about the (severe) illness and getting the patient appropriate care. They’re concerned about different things, and several factors feed in to this.”
The first is family structure. Decisions here are a family affair. You have to check with everyone: parents, siblings, cousins, great aunts, your uncle’s friend’s minister’s pet chicken. Also, when a woman gets married she basically leaves her family and becomes part of her husbands. Most of her important decisions are discussed with her husband and in-laws. Once Andy had a mother tell him that she couldn’t make a health decision about her child without first consulting her mother-in-law. Could you imagine an American woman not making a decision without her mother-in-law?
The second is language. The language here, along the south shore of Lake Atitlan, is Tz’utujil. At the hospitalito our nurses speak Tz’utujil and can serve as translators. Sololá is on the north shore. The language spoken there is Kaqchikel. It must be terrifying for patients to entrust their health to people they cannot understand.
The third is economics. “Can I afford to pay?” is a heavy question. Technically services at public health centers that are part of the national system are free. However there are still things that patients and their families end up having to pay for: transportation, medicines, certain tests, transportation to certain tests if they’re not offered at the national hospital.
The ultimate is cultural. There is still a significant amount of distrust of western medicine and the big hospitals in particular. This is partially circumstantial. A lot of people who go to the national hospitals come back dead. Because they do not go unless, or until, they are very sick.