Today we received a tour of the hospital at UNAN, Leon in Nicaragua. The hospital is pretty standard for Central America, with all the different divisions spread over 4 floors and doctors walking throughout the hallways at the usual brisk pace. During our tour we walked into the pediatric unit, where we were greeted by an American physician. Ellie is a third year pediatric resident at Duke who is performing an away rotation in Nicaragua as part of an exchange program. She invited us into the pediatric unit, where 2 patients were stationed. Ellie is a very competent physician, who cares very much for her patients. However, working at a hospital in Nicaragua has demonstrated many challenges for her. The hospital does not have a CT or MRI machine. The closest machines are in Managua, 2 hours away, and are too expensive for most patients. The perfect example is our first patient.
Priscilla is a young girl, about 2 years in age, who is suffering from a suspected interventricular septal defect and down syndrome. Upon auscultation of her heart, the murmur could not have been missed. Ellie told us that the diagnosis of Down Syndrome has simply been assigned to her, but no genetic testing or chromosome studies can be performed because of the lack of resources. In the US, genetic testing would have been performed on a young patient with a septal defect and neurological symptoms, but not here. The interventricular septal defect was also diagnosed solely through physical examination by Ellie. We decided this would be a perfect time to inform her that we had an ultrasound machine with us, and we’re eager to help Priscilla and her family with the diagnosis.
Ellie was surprised that we had an ultrasound, as the hospital doesn’t even own a portable ultrasound. We brought Priscilla into another room for an ultrasound, hoping to solidify the diagnosis. Upon imaging, there was no doubt that she has a ventricular septal defect, but also an atrial septal defect. The doctors, all surrounding our ultrasound machine, stared at the image for a few seconds before I asked Ellie when Priscilla would be able to get surgery. Unfortunately, Ellie will not be receiving surgery. The resources just aren’t available. Ellie gave a prognosis of 2 years before Priscilla would pass away. I couldn’t help but imagine how different Priscilla’s life could have been if we were back in California.
It seems that sad stories about lack of resources are plentiful here. Our second patient, 19 months old, looked the age of a typical 6 month old baby. He was very malnourished, and Ellie informed us that instead of feeding him solid food, her mother was forced to continue breast feeding because food is too expensive for the family. The baby was diagnosed with Kwashiorkor, a protein deficiency that is rarely seen in the US. The baby was put on a steady diet and has been improving, however the baby had an open wound on his neck as a result from a “cut down” procedure that was performed at a different hospital. When the baby was brought to Ellie, he not only had severe Kwashiorkor, but also had the open wound on his neck. Ellie was told to close the wound with stitches, and was unable to give any pain medication. When we asked if the baby was in pain, she replied, “Of course. But that is just how things run down here. It breaks my heart.”
Today was a harsh learning experience for me. It may sound cliché, but i learned a lot about the differences between first world problems and third world problems. Resources make a huge difference in the care that patients receive. No genetic testing available for Priscilla. no surgery available for priscilla. No help available for our Kwoshiorkor patient. It was hard knowing the pathophysiology of our patients today, and not being able to do a single thing about it. But as Ellie told us, “That’s just how things run around here.”