Overcoming Barriers, Starting at Home

Sarah Messmer, one of the original WK volunteers, is back! And ready to change our healthcare systems

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My stethoscope, a blood pressure cuff, my computer.  I placed all of these items in my bag, as Sandy grabbed her glucometer and placed it in hers.  Wicha looked at us expectantly, waiting for us to signal that we were ready to see the 8 diabetic patients we had lined up for the day.  It’s home visit time: Santiago edition.
 
We first took a tuktuk up to a more rural area of Santiago, where we found one of WK’s long-term diabetes patients, as well as two of his daughters.  We sat down on the stools handed to us and asked him how he has been feeling.  “It’s hard for me to walk,” he told us.  “My legs are weak.”  He doesn’t make eye contact, because he cannot see well.
 
 “Do you have your glucose numbers?” we asked.  “No,” said his daughters, who also both have diabetes. “We have a hard time seeing too, and we can’t read the numbers on the machine.”  We brainstormed ways for one of the other family members to check his blood sugar before they go to work in the morning.  We ran through his medications, looking through the boxes that sit on the cabinet in his bedroom.  Sandy pulled out her glucometer.  157.  “Not bad,” she said. “Especially after breakfast.” 
 
We said goodbye and started walking to the next patient’s house, a woman with both diabetes and psoriasis.  She greeted us and again offered us chairs.  She has been taking methotrexate and is due to get labs done for monitoring.  We provided her with a lab slip and talked about ways to treat the psoriasis flare she is currently experiencing.  Her diabetes, on the other hand, is very well-controlled at the moment.
 
Later in the day, we stopped by the home of an elderly woman with diabetes who is wheelchair-bound, with a chronic non-healing ulcer.  She is a newer patient for WK.  Her daughter and son-in-law greeted us and invited us in.  “She has a hard time seeing, but I think she noticed you coming in,” they told us.  “Her ulcer is looking better after the antibiotics that Dra. Waleska gave us.  We have been washing the ulcer twice daily like we were told.”  We checked her blood pressure and blood sugar, and examined her leg.  “It’s hard for us to go to appointments; she has been very confused.”  We made a plan for Sandy to check back in a week, and made sure that they have Sandy’s phone number in case her leg is worsening in the meantime.
 
Our last patient of the day was an elderly woman who has been blind since childhood.  We were let in by a woman she has hired to help her with cleaning and cooking, since she is unable to do so by herself.  “It’s Wicha,” Wicha called out, as our patient made her way to her bed, feeling the wall to guide her. “Wicha!” our patient said, glad to hear her voice.  Wicha explained to me, “She has a hard time following a diabetic diet.  The woman who cooks for her does not make diabetic foods, and she has no family to help her.  She does not choose what she eats.”  We checked her blood pressure, and told her that it was a bit high. “I ran out of the blood pressure medicine a few days ago,” she told us.  We looked through the medications at her bedside, which she distinguishes by touch, feeling the size and shape of each pill.  On the shelf nearby, Sandy found a blister of enalapril, her blood pressure medication.  “I found some right here. It fell out of the basket,” Sandy explained.  I asked her if I can listen to her heart and as I leaned in with my stethoscope, she made a joke in Kaqchikel and smiled, “Let’s see if I have one!” We all laughed and I confirmed (in my much less eloquent Kaqchikel) that she does indeed have a heart.  Sandy made a plan to come back next week to drop off more medication as well as draw blood to check her kidney function and hemoglobin A1c, a blood test to monitor diabetes control.
 
I am struck by the intimacy in these visits, and how much more I learn about patients by being welcomed into their homes.  On a different day, I visited one of our patients who was paralyzed after falling off the roof several years ago while working as a construction worker.  Every time I have visited him, he is in the same room in his house.  On my last visit with him, I asked how often he was able to leave the house in his wheelchair.  He admitted that he rarely leaves his home because he cannot get up the steep dirt slope that leads into his house, and it is a struggle to ask his wife to help him up the slope.  Instead, he spends most of his days in the same room.
 
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Doing home visits in Guatemala makes me think of the ways our health systems, both in Guatemala and in the United States, frequently fail our patients.  As medical providers, we often expect our patients to come to us and to make their way to sub-specialty appointments that are far from their homes and/or in unknown locations.  When patients do not show up to these appointments, it is not common to hear a discussion about the barriers that lie between patients and their medical care–the distance, the cost of transport, the inability to leave work, the need for child care, the lack of accompaniment. 
 
I appreciate that so much of the work we do here in Guatemala is focused on bringing care to our patients in whatever way they need – from home visits to accompaniment for complex care appointments in hospitals and other locations.  When I return to the US, I plan to bring these principles to my patients there as well–maybe even starting with home visits.
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