Friday, January 9, 2015

House calls, influenza and pneumonia...

Tuesday the community in Patanatic had a ceremony at the end of clinic to unveil the XU Interfaith Community Engagement logo that is now mounted on the entrance to the clinic. Literally every patient that walks in the door goes directly under the logo. The community elders were there with Jorge and they said blessings and words of thanksgiving. Rabbi Abie did as well with many tears of joy and gratitude. Jorge asked one of the students to speak on behalf of XU and it was Caroline. She was very poised and eloquent.

Right after that we were packing up in clinic and ready to get on the vans to travel back to the hotel when Jorge asked me if I could see a child who was ill in his home. So I took 3 of the students with me and followed the community health worker down the hill from the clinic into the village. It wasn't too far away from clinic though the terrain is so steep it was a hard walk. En route I was asking Ade, the community health worker, what she knew about the sick child. She said he was 4 and had been in the hospital for pneumonia for 4 days a month ago.

Earlier that morning I had seen a 4 year old who had been in the hospital a month ago for pneumonia for 4 days, so I suspected it was the same child. In morning clinic he was one of my regularly scheduled patients coming for a check up with one of his siblings. Mom had told me about the admission and how he had seemed to get all better for a while. But two days ago he started coughing again, though not as bad as he had previously. Then he had a low grade fever yesterday. In clinic he was coughing but playful and active. He had been playing soccer in the clinic entrance with some of the XU students just before he came in to see me. He had clear lungs so I thought he was probably getting a new respiratory virus and gave her some acetaminophen for his fevers.

She said he did fine throughout the day until about 3 pm when he felt very warm and said he hurt all over. That is when she contacted the clinic to see if I could come to the house. All of this was happening while we were at the dedication ceremony so it was probably about 4:30 by the time we got down to the house. He was clearly ill. He was also pretty frightened by 4 gringas and Stephanie Ibemere (to interpret and help) walking into his house. He cried a bit as his mom pulled him to the end of the bed. He was super hot, he had fast heart rate, ad was breathing a bit fast. When I asked him how he felt he said his whole body hurt. He probably had influenza. He wasn't struggling to breath but the fever was making him breathe fast, shallow breaths. I listened to him and found crackles, typical of pneumonia in his left upper lobe of his lungs. So I sent two of the students back up to the pharmacy with what medications I wanted.

In the mean time the remainder of the team had split - some had gone back to the hotel and some had gone with Richard to do a home visit on his sweet Valentina who we always visit and a few of the team had stayed behind awaiting us at the clinic. Thankfully Eric, our pharmacist was one of those that was still at clinic. Dakota and Shannon came running (up the steep mountain) with my pharmacy orders for Eric.

The three of them gathered supplies and came down to the little boy's house. While we were waiting for them I was giving the mom instructions on how to alternate ibuprofen and acetaminophen every 3 hours to control his fever and how to recognize if he is getting worse in case he needed to go to the hospital in Solola in the night. The little boy had just been sitting quietly on the bed and I was watching him to see if he was worsening or not. When Eric arrived with his bag of medications and graduated cylinders and colorful medication dispensing spoons the little boy perked right up and crawled over on the bed to get a closer look. It was reassuring to see the little boy still had his curiosity. He is probably the sickest acute illness patient I have seen here all 5 years. I gave Eric instructions on what antibiotic we were going to use so he started mixing it up standing at the bed side. I gave the boy, who was very attentive to Eric's workings, a dose of ibuprofen and then a dose of the augmentin as soon as Eric had it mixed. We asked mom to bring him to clinic first thing the next morning (Wednesday) at 8:30 so we could check his oxygen levels and re-assess. Again we made sure she knew what to go to the hospital for if he was worsening.

Wednesday morning mom brought him back up to clinic and he was doing great. He had not had fever overnight and by 8 pm (a couple of hours after we were in his home) he had asked for dinner. It is always a good sign to see a hint of appetite come back. He was his active self again and his vitals were all normal including his oxygen level. Each year here comes with unpredictable graces. I am glad we were here this week to see him.

It is a privilege to step into someone's home as a physician. I have been fortunate these past five years to be in many of their homes, but this is the first time I was called in to see a really sick child. In this community that lives with such economic hardship, it is a wonder how any of these children make it to their fifth birthday. They are undernourished, their living conditions make good hygiene very difficult, and their health care literacy is low. These mothers do everything they can for their children. Almost all of these kids are breast fed for the first 2-3 years of life which helps with nutrition and immunity. Every one of them are current on their vaccines, though Guatemala is not able to vaccinate against many diseases because the system cannot afford it. Influenza is one of those diseases it does not vaccinate against, so is Hepatitis A (I saw 5 kids this week that had all been diagnosed a month ago with hepatitis A). Unfortunately when you get these diseases in early childhood in an undernourished state and you live in abject poverty in a dark cinder-block house with no insulation or glass for windows to keep warm your chances of survival diminish.

This little guy will do fine with this illness. We checked in with him again on Thursday, our last day of clinic. He still had not had a return of his fever. He was still coughing, which I told mom is normal and will likely continue for a couple of weeks, slowly resolving. Now we just have to hope he doesn't get sick again or he times it to do so when another medical team is here.

Mom taught me a great tip - she tied the gray shirt around his neck and taught him to cough into it instead of his hands - that should reduce the risk of him passing his illness onto others. Simple and ingenious.

Lauri Pramuk, MD

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