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Boston vs Rural Chiapas: Comparing Cases

A 53 year-old woman walks into the emergency room of a major teaching hospital in the US with abdominal pain, nausea, vomiting, and sweating. Previously healthy, but she has not really been seeing doctors consistently. Before she even sees a doctor an IV is placed and in all likelihood will have had an EKG done. Of course to some extent this will vary with the emergency room, but this has usually been my experience. Then the history and physical are taken and performed (usually by an intern, then a second or third year resident, and then by the attending), and based on that the treatment, labs, and imaging studies are decided upon. The initial treatment would have been based on her vitals and symptoms, a fluid bolus for her tachycardia, ondansetron for the nausea, and either an opioid or a gastric cocktail for the pain (Maalox with viscous lidocaine). Studies would be ordered to determine the likelihood of pancreatitis, gastritis, gastric ulcer, serious infection, cholecystitis, MI, and even possibly acute mesenteric ischemia. These would require a long litany of labs, an abdominal ultrasound, and in all likelihood an abdominal CT with contrast. Based on those test results, and on how she responded to further treatments, she would then either be admitted or discharged from the ER.

A woman in her 50s walks into a clinic in rural Chiapas with abdominal pain, nausea, vomiting, and sweating. She is a part of the clinic’s community and has never been found to have diabetes or hypertension, or any major illnesses. She had been there three days before with some cramping abdominal pain and mild diarrhea that was felt to be consistent with giardia and was started on metronidazole, but.had since been having a difficult time keeping food and water down. As she is also a bit tachycardic the pasante (upon graduating, first-year clinicians (known as pasantes) in Mexico complete an obligatory year of social service) starts an IV, gives her a liter of normal saline, hioscina (a Mexican anti-spasmodic), IV omeprazole, and metoclopramide.

He does not have access to any imaging tests or lab tests or lab tests at the clinic aside from a point of care hemoglobin and glucose, which are of limited utility in this case. The closest hospital with imaging and timely laboratory capacity is three hours away on bad roads, and a decision has to be made. Her initial presentation was felt to be consistent with gastritis (very prevalent in the region), and although we could not rule out a gastric ulcer, pancreatitis, or cholecystitis (our top 3 alternative diagnoses) with labs or imaging, her exam was benign enough and improved so much after her medications that it was felt safe for her to go home with the caveat that if the pain were to return, she would need to go to the hospital (likely in Jaltenango 3 hours away) for further testing and treatment, with a prescription for BID omeprazole.

The first example is theoretical, the second is not. It is one of the cases that I observed and serves as an illustration of how the resources that doctors have shape their actions towards their patients. This does not, in and of itself mean that all the tests in the first example were useless or necessary, if fact, the woman came back a day and a half later with worsening pain and had to be sent to the hospital in Jaltenango for further tests. On the other hand, some of the tests done in the US are a waste of resources in the setting of an overabundance of CT scans, MRIs, medications, and bestow a feeling of false security that using them automatically makes the patient safer. This is not always true, as there is a society cost to these methods, and radiation does accumulate to harmful levels, and it can give physicians a false sense of security. For example, thinking that if the CT scan doesn’t show X, he/she cannot have it, which is rarely true.

When those resources are not available triage and trial and error must be used to determine whether a patient should take the time and expense to leave and go to a hospital far away urgently, and often if that is the case the pasante is responsible for stabilizing the patient and going with them if he/she is sick enough. But the pasante him/herself is a resource as well, and if they are gone, then the next closest trained medical professional is hours away on foot, and so they have to decide: Is this person sick enough? Do they need me more than someone else might?

Within Compañeros En Salud (CES) there is a system of radios where the pasante can ask for second opinions from his colleagues in distant villages and from supervisors, as well as do a pass-off (in the case of a rather common lack of Internet access) so that if the patient does go to the hospital in Jaltenango where CES has contacts doctors there will have an idea of what was done and how things developed. This is why patients, time permitting, are often encouraged to go to Jaltenango rather than Motozintla, which may be closer in some communities, as CES does not have any contacts there. This kind of support system is helpful for the patient and pasante as it gives both the patient a better chance of getting the getting the care he/she needs and the pasante a web of colleagues to help develop differentials and assist with adequate pass-offs, which are aided (although not always guaranteed) by proximity in the US.

 

This entry was posted in BMC.
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