Monday, December 12, 2005

My first Thanksgiving in Guyana, I woke as usual early in the morning, as the sun came streaming through my bedroom window. Brewing up a cup of tea on my kerosene stove, I settled down to read an article or two in a magazine before reporting to work at the village health post. Suddenly, I heard footsteps outside my door, and a breathless voice called out my name. Pulling on a t-shirt and opening my door, I saw one of the village schoolteachers whom I had been tutoring after school in math standing outside my house, breathless from her jog down the hill from the school, and with a worried look upon her face.

"Phillip," she addressed me, "we have a patient at the school."

Knowing that they would only approach me at my house like this if it were an emergency, I left my tea and grabbed my bag to follow her back to the school.

"What�s the problem?" I asked her as we hurried past a bamboo grove and up the school hill.

"A child, he just fall down this morning and not get up," she said.

A few more questions, and it became clear that the child had lost consciousness abruptly during the regular morning line-up. My next thought went to my counterpart, the community health worker for the village, who also owned one of the few motorboats available for medical emergencies.

"Has Rosita arrived yet?" I asked the teacher.

"No, she not come in yet."

I cursed silently to myself, knowing that this meant she was probably out of gas for the motorboat, and would be paddling up to work and wouldn't be in until later in the morning. As we approached the school, I prayed that the kid had just fainted or something and that he would come to shortly. However, my heart quickly sank when we rounded the crest of the hill where the school sat, and I saw the child in question. He was sitting propped up on a bench outside, supported by the head teacher and surrounded by the rest of the staff. He had obviously just thrown up, as vomit covered the small cream-colored button-up shirt and khaki shorts of his school-issued uniform. It had collected on the ground below him, forming a small pool of bile and rice. Though the head teacher was propping him up, I could see that the moment she removed her arms the child would collapse, as his whole body was limp. His complexion was also quite worrisome, his face a sickly pale gray hue. As my mind and heart raced, I tried to think back on various first aid training and procedures, but all that flashed in my mind's eye were visions of cheesy safety videos I had seen, and me feeling slightly embarrassed while shaking a big plastic mannequin on the floor and shouting "Jim, Jim, are you okay?" at it's rubber head and limbless torso. Snapping back to the present, I put a finger under the boy's nose and was relieved to feel his breath coming out steadily. I then tried to feel for a pulse, placing a couple fingers on his neck and wrist (did it matter if it was the right hand or left hand?) Having a hard time finding the right spot, I thought, "ah, screw the manual," and just got down and stuck my entire damn head next to his chest, placing my ear up to his heart. Thankfully, I heard a soft lub-dub beating steadily. Quizzing the teachers, I found out more about what had happened. The boy, named Simeon, had been out on the field playing cricket and running around as usual with the other children before the morning bell. Then, when lining up with his classmates to start the schoolday, he had suddenly gone limp and collapsed, the children behind him catching him as he fell to the ground. While unconscious, he had vomited up a little rice and bile, but no blood. I asked if he had a seizure, and got a no. It is a distressing thing to be looked to for help, but to feel powerless in your response.

"Let's first get him down to the health post--we have a bed we can lay him on there," I directed. A teacher hoisted Simeon into his arms, remarking on how absolutely limp the child was. He flopped like a rag doll in the man�s arms, and the image conjured distressing thoughts in my mind. I ran quickly back to my house to get my spare key to the health post, which, in my haste I had left behind. I also grabbed a bottle, filled it up with drinking water, grabbed my sugar jar, my flashlight, and my copy of the Merck Manual of Medicine. Back at the health post, I did the only thing that came to mind from First Aid training, putting the child into the recovery position on his side, with his head tilted in case of any further vomiting. When I checked his breathing and pulse again, they both still seemed stead to me, though these facts grew less and less comforting as the minutes ticked by and young Simeon failed to regain consciousness. With the school teachers clustered nervously around, I continued to run through a series of checks: eyes: closed but twitching, pupils: moving and dilated when I shined my flashlight at them, mouth and jaw: clenched, arms and legs: limp, breathing: shallow but steady, pulse: steady, complexion: regaining some color, scalp and head: no injuries. Mostly it felt like a bunch of frantic acts of desperation--me flailing about and tossing random things in front of what felt like an oncoming tank. As I mixed up some rudimentary rehydration solution (sugar water and salt) for him to drink in case he came to, and as the schoolteachers debated his condition and various substances they could use as a smelling salt, I raced through the possibilities for his loss of consciousness. If he had just fainted, he would have come to by now. Was he epileptic? But then, why hadn't he had a seizure? Could it be insulin-related? Was he diabetic or hypoglycemic? No one seemed to think he had diabetes, but with the lack of medical care and laboratory or testing facilities out here, I also knew the chances that he had ever had his blood sugar levels tested were highly unlikely. From the teachers, I learned that he had possibly had previous episodes like this.

"How do you know?" I asked.

"His aunt told us that he does fall down like this when he was little," they informed me.

"His aunt? Is she here then? Where?"

"Yes, she's at the school."

"Can I talk to her?"

Sensing my confusion, the teachers smiled and told me that the 'aunt' was younger than Simeon himself, six years old, and was at the school because she was also attending classes today too. Great, I thought, so the only relative we've got here is a six-year-old schoolgirl. By now, an hour had passed, and the schoolteachers seemed to be comforting themselves with Simeon's "more stable" condition. I suppose, the way they looked at it, remaining unconscious for an hour is a way of being stable--I mean, I guess you're not going anywhere or doing much during that time, right? Nevertheless, I was pretty sure that remaining unconscious for longer than a few minutes was definitely a cause for concern, and surely posed grave dangers to the child. As I fought my rising sense of panic, it once again struck me how resource poor and ill-equipped our villager remained in case of medical emergencies. I had no thermometer to take temperature with, or even a blood pressure cuff, as Rosita carried the only sphygmometer in her medical bag. In the adjoining room was our one medicine cabinet, stocked with a paltry and constantly dwindling supply of very basic drugs--mostly just aspirin and other over-the-counter caliber medicines, as well as a basic antibiotic or two which was surely worthless by now due to overuse and induced drug resistance.

"We have to get this boy to the hospital," I repeated to the others in the room. The brief but tangible moment of hesitation that hung in the air following these words underscored how rare trips down to the hospital were for the folks in my village. With gas prices up, a chartered speedboat ride down to the nearest town could cost upwards of $10,000GD, or $50 USD, which for many families represented half a month's earning, if not more. When some of the teachers pointed out what seemed to be encouraging signs of recovery--twitching eyelids, etc.--I repeated firmly, "We have to get him to the hospital." I didn't like the look of his utter unresponsiveness, or his clenched jaw, or the simply fact that it had already been over a goddamn hour since he had first collapsed! "Where�s the captain?" I asked suddenly, referring to the elected head of the village. I remembered that the captain had access to a community engine which was sometimes stored in the village office nearby, and which we had commandeered to take to the hospital when a pregnant high-risk mother had gone into labor early. It was at that moment that my counterpart, Rosita, arrived at the door of the health post, having paddled up the 2 or 3 miles from her home. At first she was a bit bewildered by all the confusion, but after examining the patient and consulting with me, we both decided the best thing to do would be to take the boy in the captain's boat up to the hospital. Relieved that we were finally on the move, and worried about the time that had already passed, I moved to pick up Simeon and carry him to the riverbank. Before I could touch him, however, one of the teachers said she thought we should say a prayer to wish the boy well. Biting back my impatience, I bowed my head with the others as a mercifully quick prayer was said, and then finally I was able to pick Simeon up and carry him over to the waiting boat. I staggered to the dock, surprised at the heaviness of the little boy as he hung limply in my arms. The phrase "dead weight" flashed in my mind, but I quickly banished the thought and focused on getting into the boat without toppling the two of us overboard. The boat was just a small 15 footer, with a 15hp engine attached, and the only seats were planks laid across its width. After considering these for a second, I decided to just continue holding Simeon in my arms, with his legs draped over my right arm and his head resting against my left shoulder. A teacher and Rosita joined us in the boat, and then we were off, cruising down the muddy brown Pomeroon river, the wild green rainforest on either side of us, and me with an unconscious 8 year old Amerindian boy lying in my arms. The boy's house was along the way, so we stopped to alert his family. However, when his mother found out what had happened, she insisted on trying to rouse him herself, shaking him, calling him, even taking him out of the boat to bathe him in the river. Apparently this wasn't the first time he had collapsed, she informed us. When I asked if he had seizures in the past, at first she said no. Something occurred to me, and I asked how he behaved before collapsing in the past.

"He does shake up so," his mother said, and demonstrated what was pretty much a seizure. Aha! I guess I should've figured they just might not know what a seizure was. Now I could assume the boy was probably epileptic. Anyways, we kept insisting that we should proceed to the hospital, or at least to the health center, which was only a few miles further downriver (health centers are one level above health posts in the Guyanese healthcare infrastructure--they usually have more staff and drugs available, but still are a far cry from hospitals). It was obvious that Simeon's mother was hesitant to undertake the significant financial burden of a trip all the way into town. When I first arrived in my village, I was shocked and upset by the residents' hesitancy to pay for a trip to the hospital, even in the face of medical emergencies. When that high risk mother had gone into labor, I remember running around frantically like a chicken with its head cut off, trying to convey a dire sense of emergency to the other villagers, and becoming dismayed at their seeming lack of concern. However, by the end of that day I had learned a lot about the reasons behind the villagers' hesitancy to go running to the hospital for medical help. For one thing, when we arrived a the first hospital, no doctor or even a qualified midwife was on duty to handle deliveries. Secondly, the treatment the mother got from the lone nurse and nurse's assistant who were on duty bordered on abusive--disgruntled looks at this interruption of their lunch break, derisive comments about the mother's intelligence, manhandling when it came time to do a preliminary exam, etc. Indeed, when we found out that it would be necessary to transfer the mother to yet another hospital, my counterpart expressed relief on behalf of the mother, explaining quietly to me that she probably would receive better treatment this way, as "the nurses here do be rough." Even so, we found out later that though the baby was delivered alive, it passed away a few hours after birth. Though this outcome was particularly bad, it was still fairly illustrative of the shoddy medical care that villagers could sometimes be subjected to when coming into town for treatment. In the developing world, where quality medical care is already in short supply, it certainly does not help to be a member of the most underprivileged minority group, as aboriginal peoples often are. Thus, at first glance, the hesitancy to pay for the hospital trips could be seen as a sign of ignorance concerning proper medical care, or worse, selfishness and excessive frugality. However, taken in the context of absentee doctors, continuous "referrals," abusive treatment, "invisible minority" status, and other ills of an unsatisfactory healthcare system, the hesitancy to seek out such unreliable medical care isn't just understandable, it actually makes sense. I mean, who wouldn't think twice about coughing up half a month's pay for something that isn't guaranteed to help you at all? When a people have come to expect so little in a system, how can you ask them to have faith?

Nevertheless, back in the boat, we still felt that young Simeon should at least travel down to the health center, especially when several minutes of his mother's efforts failed to produce any further signs of improvement.

Unfortunately, the person in charge of the health center (along the lines of an RN in the States) had left just the day before to seek better pay and opportunities in another country. With a replacement yet to be found, the health center, as well as the surrounding villages such as ours that it served, was now without its most qualified health professional. This loss of the most educated segment of a population is endemic to many developing countries, and Guyana is no exception to such "brain drain." Despite this absence, at least the support staff at the health center would be able to put an IV line in Simeon and to administer glucose and fluids, and would be better equipped in general should his condition worsen. With this reasoning, we finally convinced the mother to take her still unconscious son back into the boat. It was only when we had stopped again, to transfer gas and our passengers to Rosita's faster motorboat, when Simeon finally began to rouse himself, nearly 2.5 hours after first losing consciousness. By the time we reached the health center, he was fully awake once more, though still rather weak-looking and quiet. He disembarked and trudged up the dock with his mother, while I stayed behind for a moment to tie up the boat and explain what had happened to the Peace Corps Volunteer who works at the health center. She also happens to be the closest American living nearby, so after discussing Simeon's case with me, she paused, then turned back and called out to me as I was unloading the boat.

"Hey Phillip," she said, noticing what date it was.

"What?" I asked, looking up from the riverbank.

"Happy Thanksgiving."