Internal Medicine rotation in Rural health clinics in Chiapas, Mexico Part 2

David A. Cardona Estrada, M.D.

Internal Medicine Resident, North Shore Medical Center

PGY- 3

March 18, 2019

During medical training, we often develop a superficial sense of control over the natural course of disease processes. There is such an overwhelming emphasis on data, diagnostics, and evidence-based practice, that we often lose our humanistic perspective. We forget that having a disease, whether chronic or acute, is just a small part of our patient’s lives, particularly in our most vulnerable patients and populations.

While providing medical care in Chiapas, Mexico, I quickly realized just how impactful socio-economic factors are in determining a person’s health and wellbeing, as well as access to basic medical care. In a resource-limited environment, the challenges encountered when making diagnostic and therapeutic decisions can be quite complex and challenging, to say the least. Lack of resources combined with a population that lives well below the poverty line creates a unique medical and moral challenge that is rarely encountered in well-developed countries

These challenges were exemplified with one particular scenario that I encountered during my time in Chiapas.  “Mrs. V” was a 40-year-old female, who presented to the clinic with a two-day history of persistent, intense right upper quadrant pain. She had a history of similar pain in the preceding weeks, which was triggered by heavy meals, though the pain had previously remitted spontaneously. On exam, she was afebrile though tachycardic. She appeared non-toxic but her abdominal exam was concerning; guarding, significant tenderness to palpation, and a blatantly positive Murphy’s sign. Our immediate concern was evolving acute cholecystitis. 

Community of Laguna del Cofre,
Sierra Madre Chiapas Mexico

“Mrs. V” had been evaluated earlier that week by another physician who had performed an abdominal ultrasound. The physician had advised surgery; presumably a cholecystectomy. She also was prescribed a medication, which she unfortunately could not recall the name of, and was unsure if it was an antibiotic. To further complicate matters, “Mrs. V” did not bring the report of the ultrasound nor did she have the ability to read the report anyhow. Her clinical picture was concerning.  In the ideal setting, she would have basic labs, right upper quadrant ultrasound, and a surgical consult.  In this scenario, the nearest medical facility with basic ultrasound capability was 2 hours away, and the only means of transportation would require pay-out-of-pocket, which was an unrealistic option for her. 

Herein lies the dilemma:  If she did in fact have cholecystitis, she would have to travel to the capital city, which would require a 5-hour trek through mountainous terrain with unpaved roads.  The logistics are well beyond the scope of what Mrs. V and her family could coordinate, not to mention afford.  Food and housing for family members, transportation, and payment for services received while in the hospital were just a few of the foreseeable obstacles.  Unfortunately, she was from one of the poorest families in her village.

As I began to discuss my impression and potential plan with her, I explained the importance of an ultrasound which would cost her ~$20 US.  She promptly expressed that it was the coffee harvest season and that if her husband took her to the ER, they simply would not have money to feed their family.  I was stuck between a rock and a hard place. Do I recommend traveling to the nearest hospital for an ultrasound, with the possibility of this being only biliary cholic at the risk of not being able to feed her family? Should I sit tight and watch things evolve? What if she decompensates?  If that happened, then we would have to emergently send her to the closest city, which again would be a dangerous and expensive 5-hour drive. 

There was no “right answer”. We did what we could, with what we had, in the given moment. Our organization had arranged for a general surgeon (with ultrasound capabilities) to visit the town closest to us, though this would be in two days time. We gave her oral antibiotics, analgesics, and urged her to return in 2 days for a cost-free surgical consultation.  My decision weighed heavy on my conscience and I could not sleep that night. I was troubled by fact that someone has to decide between paying for basic medical care and feeding her family. The outcome was favorable and Mrs V. had no complications. She eventually had her ultrasound which showed gall stones without cholecystitis.