Reconocido
2003; Elsevier BV; Volume: 42; Issue: 5 Linguagem: Inglês
10.1016/s0196-0644(03)00626-7
ISSN1097-6760
Autores Resumo“Doctor, this ship is leaving, and so is your patient,” the captain said. “I'm going with her then.” For 3 weeks of this cruise to Central America, I had counted as potential patients all 800 passengers and 300 plus crew, 12 officers, and various performance artists and lecturers, but never a Guatemalan school girl who could die this Christmas Eve. Each year on Christmas Eve, the ship pulls into Port Quetzal in Guatemala as part of its year-end schedule for cruising from the Bahamas along eastern Mexico, through the Panama Canal, and up the Pacific Coast to Ensenada, Mexico. Each Christmas Eve, the ship opens its doors to hundreds of Guatemalan boys and girls. They sit at tables set up in the midship lounge. They eat cookies, make Christmas cards, and receive gifts from Santa that the passengers brought aboard specifically to donate to the children of Guatemala. The children love it, and the passengers feel good about making Christmas special for some poor children in Guatemala. This year, one child would not make it to the midship lounge. I was looking out the porthole window of my stateroom when the buses holding the Guatemalan children eased onto the pier. Children began streaming out to line up at the ship gangway. The 4 school buses were labeled incongruously “Austin Schools,” “Alexandria School District,” and with the names of 2 other US cities. Our tour guide had explained earlier that day that all Guatemalan buses are old US school buses that are seldom overpainted. One look at the old, tattered clothes of the kids revealed that these were not US kids, and the chaperones appeared to be nuns in full habits. Catholic schools and church orphanages usually answered the invitation to spend Christmas Eve with us. My radio crackled as someone in gangway security called for the ship doctor to come at once. A girl had vomited and collapsed. On the way off the ship, I lucked into meeting Laura,∗ a fellow passenger and Spanish translator in a US emergency department. She had seen the girl and was looking for me to help her. Laura and I found a slip of a girl with dark skin and black shoulder-length hair crying and doubled over, holding her stomach and lying on the stained boards of the pier. Her name was Lesli Luz. She was attended by Hermana Jesusa, a woman of perhaps 24, who helped run the convent school where Lesli was a student. I began asking questions in Spanish, but fortunately, Laura stepped in. “Lesli has been vomiting since she got off the bus, and has had stomach pains and vomiting off and on for a few months. She and Hermana Jesusa are asking for our help.” There were about a hundred people looking at us, both other students and many passengers lined up to board the ship after the day's excursion. “Let's take her to sick bay,” I said, and picked her up. I carried her up the gangway and to the infirmary in the bowels of the ship. After I set her down, she began to walk, then vomited twice. About a quart of clear vomitus covered the black-and-white tiled floor. She began to cry again and hold her abdomen. I quickly introduced Lesli and Hermana Jesusa to the surprised but unflappable registered nurses on the ship. The head passenger nurse, Celeste, motioned to place Lesli onto the most comfortable bed in sick bay. Her blood pressure was 110/70 mm Hg, but her pulse rate was 140 beats/min. We discussed the symptoms, and I had Celeste give Lesli intramuscular phenergan. Laura tried to speak with Lesli, who didn't speak much, and then with Jesusa about Lesli. It seemed that Lesli had had abdominal pains off and on for several months. A doctor saw her a few months ago without a diagnosis. The doctor then declined to see her because the convent couldn't pay his fee. “Can't you do something?” said Hermana Jesusa. I had Laura ask about what Lesli might have eaten. Laura said that about 4 hours ago Lesli had eaten a partly cooked tamale called a “reconocido.” Apparently, for Christmas and other holidays, Guatemalans love to cook tamales, a mixture of tomato, vegetables, raw meat, and cornmeal that reminds them of childhood and is, therefore, called “reconocido,” or “memory.” It takes a full day to cook. Lesli had eaten the tamale before it was fully cooked. Food poisoning should run its course, I reasoned; Lesli was dehydrated and needed to drink. I asked Celeste to begin oral hydration soon. I then went to midship lounge and made sure to collect a bag of gifts for Lesli. Soon the ceremony ended, and Lesli's schoolmates began filing off the ship. When I went down to sick bay, I became concerned. Lesli had drunk only a few ounces of water. The phenergan sedated her to somnolence, and she was still dehydrated maybe a full liter. Repeat pulse rate was 140 beats/min. Her capillary refill seemed slower than before. Celeste said, “Bob, we have to send her ashore with the others. It's 8:30 pm, and the ship is supposed to leave port at 9 pm.” “She's still dehydrated,” I said. “We need to start IV fluids.” “I'm not going to start an IV on her,” Celeste said. “Besides, we can't keep her here.” “I'll start the IV,” I said. “And we need to alert someone on shore that she needs ongoing medical care.” Laura translated to Hermana Jesusa. Laura told me, “There is no one who can continue IV fluid tonight. The hospital requires money in advance and is closed right now anyway.” I got a 20-gauge IV in her hand vein, hung normal saline solution as high as the bag would go, and squeezed it as hard as I could. It was almost 9 pm. One-half liter was infused. Laura and the nurses looked at the clock nervously. The captain called on the phone. “How is the girl?” he asked. “Not good,” I replied. “She's dehydrated from vomiting, and we're giving her IV fluid now. She needs more fluids.” “Bob, you know we are leaving for Acapulco in a few minutes. We can't take her with us or she's considered an illegal alien, in effect, a stowaway. Mexicans do not treat stowaways well, not even children. We have to get her off this ship.” “But there's no one who can continue her care in Port Quetzal,” I said. “We need to leave by 9 pm or we won't get to Acapulco by our scheduled time. That means every minute here is a minute later for bringing aboard the harbor pilot, for crew training, and for shore excursions.” “Well, one of your medical staff may have to go with her to continue her IV fluid. She could do very poorly tonight without it.” I looked around. None of the nurses were volunteering to go ashore with her. “How can you go ashore?” The captain was in full command mode, even over the phone. “You all are contracted to be the ship's medical staff, and we need you here on the ship.” “In the States we'd have to transfer care to someone of equal or greater medical ability,” I pleaded for understanding. “It would be abandonment to leave her on the pier dehydrated.” “But we're not in the States,” said Celeste, loud enough for the captain to hear it over the phone. “There just isn't the medical care here for anybody. It's not illegal here.” “But is it unethical?” I asked. “Besides, it's Christmas Eve, and I'm not leaving this girl until she's better. And I guess I'll be the one going ashore with her.” “You can't go ashore,” the captain said. “Then we stay here,” I said. “Come down and see for yourself.” The captain was a tall, beefy Swede who was known to deal severely but fairly with officers and crew. He looked at the girl and spoke through Laura with Hermana Jesusa. The captain turned to me and said, “How much longer do you need?” “Not sure. Give us 30 minutes,” I said. “You've got it, then we sail,” he said, pointing at me, then at the girl. “With you and without her.” He was seeking a deal. As if it were really up to me. “If she's not better, let me speak to the passengers about the reason for the delay. They will understand.” The captain left without comment, but seemed visibly moved by the little girl curled up on the bed. The nurses, Laura, and I prayed with Hermana Jesusa for Lesli to get better. In case that didn't work, I asked a cabin steward to get my overnight bag from my stateroom with my passport and some cash. Barbara gathered 2 more liters of intravenous fluid and some phenergan tablets and suppositories. Then, Laura and I wrote up a full note in Spanish to the local medical center with Lesli's medical history, examination, and treatment. I added a plaintive note to please examine her, continue treatment, and return her to school. I promised that the ship would be checking in when it returned in 2 weeks, and that the captain himself had seen her and was interested in her improvement. The radio hissed with the orders to start engines, secure gear, cast off lines, and confirm that everyone was aboard. “Standby to raise gangway,” the safety officer radioed. It was the moment of truth. The IV hung empty. Lesli's new pulse rate was 100 beats/min. I gently rocked her. Lesli suddenly opened her eyes, sat up, and smiled broadly with teeth gleaming white against her dark skin. She turned to hug Hermana Jesusa, then stood and hugged me, Laura, the nurses, and then Laura again, bubbling in Spanish. “She says thank you very much, and merry Christmas,” Laura said. We hurried her off the ship with bags of gifts, including a few extras that the crew brought her. We put her into the arms of the convent sisters with extra medicine for nausea, packets of electrolyte to dissolve in water for rehydration, and the note from us to the local health clinic. It was truly divine intervention (and a little phenergan) that helped a little girl get better. It was God's gift to me not to have to choose between going ashore with this girl or staying to care for passengers and crew. It seems clear to me that every emergency physician I have worked with would have struggled with the same decision, even if it wasn't Christmas Eve and even if it wasn't a slip of a girl in Guatemala.
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