During our first clinic day in Cayo de Agua, I had just transitioned over to the provider role when I heard our clinic manager Jack discussing a potential emergency home visit that would need to be done. Apparently somebody had come to clinic asking if we could see her aunt in her home emergently. As soon as I heard this I beelined to Jack and asked if I could be a part of the visit. He agreed and said I could go with Anne – a Dutch pre-clerkship medical student – and Eliza – a surgically focused physician from the Netherlands.
All that I had heard so far was that this patient was experiencing severe chest/abdominal pain (unclear which at the time) and had seen us once before several years ago – so no recent medical history. I began racking my brain for what could be going on and trying to prepare a go-bag of tests and whatever medications we may have that could be of use – intake supplies, portable EKG, aspirin, analgesics, anti-emetics, etc. Unfortunately we no longer had access to a portable ultrasound which was a huge letdown (and another motivator for me to go purchase one of my own).
Once Eliza was ready, she, Anne, and I followed this girl to her home. The story that we were told was that her aunt had severe pain in chest/stomach and could not get up for the past several hours. Along the way, Eliza told me that she remembered I plan to specialize in emergency medicine so she would sit back and supervise as I ran the case and Anne performed intake. I was so grateful and excited for the opportunity.
After a 10-15 minute hike to this patient’s home right on the water, we entered their home which was full of people and found our patient lying on her cot on the floor – sweating and clearly in discomfort. In Emergency Medicine, one of the first questions you learn to ask yourself and intuit is “is the patient sick or not sick?”. This patient was sick. I knelt down and introduced myself and the team and began the visit. With several questions and suggestions interjected by Eliza, we quickly came to the conclusion that she very likely had acute cholecystitis (inflammation of the gallbladder) and was in need of emergency surgery. As soon as we realized that she was likely suffering from cholecystitis, we were wishing that we had access to an ultrasound because cholecystitis can be evaluated and confirmed via ultrasound. However, we had to trust our clinical judgement and we knew that regardless she needed to be sent for surgical evaluation.
In Holland or the USA this would have been a simple case with a phone call to the on-call surgery team. However, we were presented with a whole host of social issues to overcome. The family had no money to afford the trip to the city for surgery. The family had no money to afford the surgery. The family had rarely ever gone to the city and was terrified of navigating it alone. We didn’t know if/when we would be able to follow-up with the patient. We didn’t know if we’d even be able to convince the doctors in the city hospital that she does in fact require surgery. We included the family as much as possible in our thought processes and told them that we would return in an hour or so after consulting with the rest of the FD team on how to proceed.
We made the hike back to clinic and reported to our provider in charge for the day along with our clinic manager who has more understanding of the local healthcare system than anybody else on the team. Eventually, a decision was reached. Our plan was to bring the patient and one family member who can care for her. She would be picked up by one of our boats at her house and accompanied the entire time by Eliza and one of our other FD staff members who was still at base. FD would fund as much of the patients transportation and medical costs as possible. The patient would be followed-up with in two weeks when FD returns to a nearby village for another clinic. And to make up for the loss of one provider (Eliza) for the remainder of the clinic week, Nica and I would fill in as providers (while still reporting to a supervising physician, of course).
After we returned to base clinic on Thursday, I anxiously awaited an update from Eliza. As it turns out, the patient was initially discharged from the ER when they couldn’t find anything on ultrasound. But that evening, she decompensated again (in the city) and was brought right back to the ER at which point they agreed that she was in fact suffering from cholecystitis and scheduled her for a cholecystectomy first thing in the morning. She had the surgery done laparoscopically and tolerated the surgery extremely well and recovered and was discharged within a couple of days. Eliza and one of our other FD staff members – Kevin, who is from the city that the hospital is in – accompanied and advocated for the patient and her mother the entire time. This ended up being such a help because of the social issues mentioned prior. I am truly grateful that they were able to be there with them.
Two weeks later, I’m back on my couch in my living room in Atlanta, GA, and I receive a text from Eliza. She had a follow-up appointment with our patient and she says that she looks like an entirely different person (in a good way).