Third World Ambulance
A third-world ambulance, or at least the equivalent, was what brought the man into the mission clinic. Machetes in long, effective strokes, had been used to take the bark off of a young tree earlier that morning. Eight feet long, four inches in diameter, with a bone-white cambium layer of wood still obviously moist with sap - this pole was supported on either end by two young men. In the middle of the long pole was a hammock, colorful and weighted with the body. He was hidden within a faded, striped, clean fitted sheet, that was draped over the whole apparatus to assure that his condition was shielded from prying eyes.
Nicaraguan families by the hundreds have patiently waited in long lines in the heat of midday. Disney World’s crowd-control could have inspired the queues in Achuapa, a little village in the mountains of northern Nicaragua. At the end of the snaking humanity is our visiting medical mission team. We are predominantly well-intentioned gringos, consisting of eight nurses, one NP, one native MD, and myself as PA, staffing this temporary medical clinic in a two-room school house during holiday. We treat infants, families, the young disabled, the elderly, and none have been turned away. This Baptist Medical & Dental Mission seeks to minister to the spirit, but once the church service under the big tent is done, the line for the medical clinic grows throughout the day.
Moving past the people, trees and buildings, the third-world ambulance traveled ahead of the pack, simply ignoring the crowds. Respectful for this patient’s status, everyone defers to permit access to the temporary clinic. "Older than stated age" might be a description that fits this 38-year-old who looks seventy. Cachexic, dried-up, gray skinned, with unshaven stubble, he is flexed into a fetal position by the hammock. Juan is my latest patient. With many hands, he is transferred onto our only bed and makeshift curtains are drawn.
North American body builders may lust after a washboard abdomen, but in a lean person, the classic textbook presentation of peritonitis displays the exuberant muscle irritation and spasm of a hot, hard belly. No bowel sounds and blood in the stool. Pain throughout the exam is reflected in his face, but no moaning is heard. Listening to the chest, the heart is tachycardic, respirations shallow. Oddly, the skin has a startling crackle under the pressure of the stethoscope. Similar to the sensation of fingers popping bubble-wrap, it is further cause for alarm: subcutaneous emphysema. Air is leaking out of the lung and into the under-layers of skin. We are all puzzled. Peritonitis and subcutaneous emphysema? The man is deathly ill, but this combination seems almost contradictory.
Tropical medicine is a discipline almost entirely ignored in the First World. Our affluent society concentrates on early detection of cancers, reducing cardiac risk and even surgical aesthetics. We strive to rescue children from life-long disability. We treat the penalties of living abundant lives, including multiple co-morbidities in geriatrics, surgery for transplantation, and bariatrics, as well as end-stage failure of minds.
In Nicaragua, malnutrition and contaminated water are common. Maternal and fetal mortality are unacceptably high. Near-universal diseases include worm parasites, infestations, fungal skin, and the profound debilitation of untreated mundane ailments. Gringo doctors don’t see end-stage tuberculosis. They don’t encounter large destructive lesions, which start at the lung, erode through the diaphragm, and perforate the bowel. At least, that is the epiphany we feel when our Nicaraguan doctor says simply - TB.
The clinic is a lightweight affair. No oxygen, no airway supports, no intravenous medications except plain saline. No real solution for this man. He will die in the coming hours, or worse, in days. One of the preachers comes to offer prayer. Family has gathered closely as we describe the clinical reality. Death is inevitable. The news is no surprise, but deep disappointment is palpable in eye-to-eye contacts with the visiting clinicians.
Humbled, weary, gritty, we all seem momentarily frozen, with a mix of hospital urgency and funereal grief, amid the crowded, makeshift clinic. The line of hundreds is still patiently waiting for us in the heat of day. Unmet needs remain. And for all of us, our day is short.
Lahut T. Third World Ambulance. The Internet Journal of Allied Health Sciences and Practice. 2009 Jul 01;7(3), Article 6.