I thought I might be broken in gently to the new job, but I arrived last Friday in Santiago, and was thrown into a 24hr on-call in the ER on Saturday, which was thankfully remarkably quiet.  Sadly I have had to convert to transatlantic terms, as when I use the term A+E, my American colleagues seem to think I’m talking about the cable channel ‘Arts and Entertainment’. 

The emergency services here, or ‘bomberos’, are a group of volunteers with no paramedic training.  They respond to any disaster, including fires, murders, and sick patients, but unlike back home, we don’t get a warning shot before they turn up. 

We were poorly prepared for a 32 year old, who had miscarried at 20 weeks, and was bleeding profusely due to retention of placenta.  For some reason, which neither myself nor the nurses were able to elicit, the family had not wanted to bring her to hospital, so by the time she did get here, she had almost exsanguinated.

We managed to gain control with an unbelievable 8L of fluid (we have no blood available here) and a D+C under propofol.  Despite my scant experience with propofol, I was all too aware that leaving a 4th year to bag and mask, with intubation facilities being at least a 5 minute set up away, would not be acceptable practice back home.  Thankfully I was too busy removing placenta to consider the Michael Jackson related implications which were pointed out to me later.

With ongoing bleeding, and a circulating volume of salty water, it was clear when the situation stabilised somewhat, the patient needed blood, meaning a transfer to Solola, an hour and a half away.

Amazingly, this was where the difficulties began.  I’m not sure whether it was a misconception of the gravity of situation, although this was explained in very frank terms, but it took a further hour of negotiations with the family before they would allow us to transfer.  It was of course made much more difficult by language, but there were discussions regarding money, after which the husband left to go and find the rest of the family to discuss.  They returned with a priest to say a prayer, and then slowly, slowly agreed to go to Solola.  With the clock ticking, it was very difficult to watch, stand back and allow time for the family to discuss.  My brain has been programmed to act quickly, particularly in the case of a 32 year old woman with a treatable cause of instability. The option of not doing wouldn’t even cross my mind, and nor would it ever be a decision encountered back home with a previously well young person.
  
The way it works here is very different for a number of reasons related to resources, education, culture and economics.  A husband can decide not to seek care for his dying wife because of the cost of transfer, and a parent can choose to take a desperately sick child home because they feel that being at home is better for the child than intravenous antibiotics.   I’m yet to a get a full picture of the factors that contribute to these understandings, but the nurses and other doctors are gently coaching me in the ways of rural Guatemalan healthcare.

There was certainly an element of mistrust about what I had tell patients is necessary, perhaps of the western nature of treatment options, but there have been situations here where the final decisions by the family have come down to finances.  I find this particularly difficult when treating children, as I would have thought the parental instinct would have over-ridden any financial implications which may follow treatment.
A friend suggested that perhaps they are accustomed to losing children, that it is much less shocking and unusual than I consider it.  Or perhaps understanding of the situation and consequences is hindered by a lack of education.  Back home we are bombarded with health advice and warning signs, for example the meningitis campaign, and with a basic level of education most families are able to interpret such advice and seek help.

During my shift, one of the nurses put a hand on my shoulder and stoically told me, ‘you do what you can’. I finish at 7.30 tomorrow morning, so before I start trying to tackle the issues of rural health provision, I plan to hunt down some decent chocolate and do what I can – make some brownies.

Louise Kenny has completed F2 year in the Northern deanery and is now working in Guatemala