It usually comes to me in a super market, sometimes Wal-Mart. This time, it was in a Chili’s restaurant in Miami International Airport. I was returning from 6 weeks in Guyana and the bustling airport led me to seek refuge in a restaurant. The burger I ordered, with a thick slab of bacon, nearly overcame me with emotion. It wasn’t that it was such an incredible burger. It was my reflection, the contrast, of the place I often take for granted and the place I was returning from. The excess we have become accustomed to. Something so simple as a good burger is not obtainable everywhere. Many things aren’t.
The Emergency Department at GPHC, Georgetown Public Hospital Corporation, the country’s tertiary care facility, is busy. It sees about 70,000 patients per year. The House Officers and Residents work tirelessly to sort the truly ill from the baseline chronic disease present in the population. I spent the majority of my time consulting on patients, standing at the bedside, and teaching the Emergency Medicine Residents and House Staff alike on the care of acute and chronic illness. Often, as I went through the differential diagnosis of the patient, I would realize, we might never discover the exact cause of the patient’s illness. Many of the diagnostic tests so easy to obtain here, are simply not available. Blood cultures, to determine the infectious bacteria of a septic patient, aren’t easy to obtain. A CT scan of the head, often ordered to excess in the US, is expensive for the population of Guyana, sometimes costing a months salary for a test that may be negative or have little impact on a patients’ subsequent care. Cardiac enzymes, used to diagnose heart attacks, aren’t readily available. And, even if they were, neither is a catheterization lab. I had to ask myself often where to draw the line between teaching good care and teaching appropriate care.
The patients presenting to the emergency department in Guyana are often complex. In addition to the ills that face patients in the US, tropical disease such as Malaria, Dengue, and Typhoid are present, complicating the clinical picture. One child in particular nearly died from something so simple as touching a caterpillar, the most toxic known. TB was a common complaint and is seen daily at GPHC, often in advanced stages. At times it seemed as if the taxi drivers are actually aiming for the children as they make their way to school, so common is their appearance in the trauma bay with broken bones and head injuries. Those injured in the interior, the jungle, often have to endure many hours over rough inland roads, or a choppy river, to reach the hospital. I was often surprised by their survival and endurance of what must be agony, only to be gracious for the care provided. Those intubated in the emergency department are ventilated by hand until a ventilator can be found in the ICU, sometimes hours later. The nurses often take turns ventilating with few complaints.
As I choked down my burger, I thought back to the infant with meningitis, gasping for air. There was no spinal needle for children that would allow a lumbar puncture. Despite aggressive treatment and antibiotics, the baby succumbed, as did another a few days later. I recalled the young lady that presented with mild confusion and fevers. In a matter of a few hours she was unresponsive with a dangerously low blood pressure. I spent hours at her beside with the residents, struggling to keep her alive, without the rapid tests that would give me the cause. One resident intubated and another started a central line. Fluids, antibiotics, and multiple drips were started. A lumbar puncture and an ultrasound were performed. We wracked our brains to discover the missing piece of information that would keep her alive, a diagnosis that fit. Her husband, whom I kept updated, was brought into the room. I told him she was gravely ill, and would not likely survive. I encouraged him to talk to her and say anything he wanted. He whispered into her ear and kissed her on her cheek before walking away, sobbing. Our efforts were not enough. She died a short time later.
Despite the challenges and material limitations, the physicians are eager to learn. Suggestions to improve care are readily embraced by residents and management and solutions are sought to overcome an often challenging work environment. In my short time there, through the work of many people, I was able to secure a readily available supply of much needed blood for trauma patients. A resident is now teaching the calculated administration of vasopressors to other interns and sharing new knowledge to improve patient care for the local population. By saving patients that would have died just a few years ago, they are learning to be hopeful as they provide compassionate care. These things, it seems, are available everywhere