Bush Medicine

Some days here in Nicaragua medical care seems fairly straight-forward. We see patients at the MINSA clinic and diagnose ear infections, respiratory infections, stomach bugs, and parasites and treat them with antibiotics and antiparasitics. It´s just like a family care practice in the States, except for the parasites. :)

But some days we have emergency transports to the hospital. We turn the back of our truck into an ambulance by laying a mattress down, and we drive two hours on a dirt road, bouncing all the way because we don´t have shocks, and using the transmission to slow the truck down, because we don´t have brakes. In the States, the same distance would take perhaps half an hour, because the road would be paved. Also in the States, I would have a fully equipped ambulance so I could actually care for my patient on the way to the hospital.

On Tuesday, January 6, we took a patient to the hospital who was having convulsions of some sort. Mindy said they didn´t look like seizure convulsions to her, but they certainly looked bad, whatever they were. The young woman would start thrashing around agressively, obviously not in control of her body. Her fists were clenched so tightly her nails were digging into her palms, and she was screaming in obvious pain and terror. Her eyes looked strangely glazed over. The only thing we could do for her was hold her down to keep her from hurting herself.

We got her to the hospital, carried her in, and laid her on a bed in the emergency ward. She was still convulsing violently - three or four people had to stand next to her bed and hold her at all times to keep her from falling on the floor. A doctor came in with an injection to calm the convulsions. But all of a sudden, the girl´s mother started saying no. She refused to let the doctors touch her daughter and said that she wanted to take her to a sukia (witch doctor) instead. I was listening to this conversation in Miskito, and couldn´t understand what was happening. All I could gather was that the mother was saying something about the doctors at the hospital not speaking Miskito. Which is true - that particular hospital is staffed solely by doctors from Cuba, which is one of the things that makes it a good hospital. But in this case, it apparently contributed to the mother´s distrust of the hospital.

I tried to ask the other friends and family of the patient what was happening, in Spanish. One young man told me that the mother wanted a witch doctor, but he used the Spanish word for it, which I didn´t recognize. Suddenly the people picked up the mattress and carried it outside. not knowing what else to do, I stayed with my patient and helped. While we were carrying her, Janet told Jenny what was going on, and she told me, so I finally knew that they were taking her to a sukia.

They loaded her onto a pickup truck in the street outside the hospital. She was still screaming and convulsing, and I felt desparate to get her help - real help, not whatever dubious ¨care¨ the sukia would provide. But how to communicate? I didn´t think the mother spoke Spanish, and I couldn´t say what I wanted to in Miskito. I started trying to convince the friends and family, in broken Spanish. But I was talking to the wrong people, and I was too late. The mother had decided, out of her fear and ignorance, that her daughter would be better off with the sukia than in the hospital. The truck left before I had barely started making my case.

The next week, on January 12, I met another case that tested my limits. Sunday night around 8pm, a woman in Santa Clara walked under her house. From what I could gather, she was chasing a chicken. All the houses here are built on ¨stilts,¨ so you can get under them easily. While she was down there, a beam fell from the underside of her house and struck her. They came to our mission the next morning to ask for medical transportation.

When I got to the patient´s house in Santa Clara, she was lying on the floor moaning with pain. They showed me the places on her left side and abdomen that were hurting her, and then they rolled her over and showed me her back. She nearly screamed when they moved her. There was a lump near her spine halfway down her back, where I assume the beam had hit her. Just the gentle pressure of my hand touching there hurt her badly.

All the medical training in my head said I needed to keep the patient´s back straight, because it might be broken. In the States, that would involve strapping her to a back board, chalking her head, and packaging her in a Stokes basket for transport. Here, of course, I have none of that equipment. So I had to get creative.

In my own quaint mixture of Spanish and Miskito, I told the family her back had to be straight, and asked them to get a piece of wood. They came back with a 2 by 4. I tried to explain log rolling to them, and we got the patient on to the board without bending her spine too much. Then they put the board and patient in a hammock and carried her out to our truck.

As we drove out of town, I wrapped some rope around the patient and the board to secure her and keep her from bouncing off. Then I tried to show her family how to hold C-spine on her head to keep her neck straight. I ended up doing it myself most of the way back to Francia because they couldn´t understand.

We took the woman into Janet´s MINSA clinic. Janet started an IV, gave her diazepam to calm her down, and inserted a urinary catheter, because the patient had not been able to urinate since the accident. Mindy got some webbing from the hill, and I took the opportunity to do a better job of patient packaging. The result still looked ridiculous, but I hoped it would hold until we reached the hospital.

It did. We carried our patient into the emergency ward. I was happy that I had kept her back straight, but knew it hadn´t been straight the whole night she spent in her home. And then when the doctor arrived, he untied the ropes and pulled my board unceremoniously out from under her - no log rolling involved. Why did I even bother, I wondered.

I felt so helpless in both these incidents. I didn´t have the words to get proper care for one patient, and I didn´t have the equipment to care for the other. I did my best, and that´s all I can do, but I stuggle to accept that truth. As an American nursing student, I have a concept of the ¨right¨ way to do medicine. Unfortunately, that way doesn´t always exist here.