Inés Fernández’s kidneys no longer work like they should. Since September, an ambulance takes her four days per week from her house in La Cruz to the Enrique Baltodano Hospital, in Liberia, so she can have kidney dialysis, a medical procedure that substitutes the functions of these organs.
She’s 43 years-old, has three children, used to clean houses and is one of the 115 patients with Chronic Kidney Disease (CKD) at the Enrique Baltodano Hospital in Liberia and one of the 177 patients in the medical centers of Guanacaste.
Inés is in intermittent dialysis care in which specialists teach her and 20 other patients how to cleanse themselves - as they say in peritoneal dialysis.
Meanwhile, they wait for these sick people to set up a space in their homes so they can perform dialysis and become ambulatory patients, which is now done at home for 92 people.
If she can prepare her room with a level ceiling, lavatory and bathroom, Inés could live for six years, the approximate life expectancy for a person with CKD. But doing so won’t be easy.
“The vast majority of our patients live in conditions of poverty and extreme poverty, which is why intermittent dialysis is a creation specifically for Guanacaste, because many of the patients that required dialysis as treatment didn’t have adequate living conditions,” explains family doctor Mónica Espinosa, one of the specialists that attends this population.
Carlos Gómez, 43, is part of the intermittent dialysis unit in Liberia.
Inés, like many others, hopes to be able to prepare her home. She is trying to put together ¢2 million ($3,570.00) with the help of her two of her sons and with the disability money she receives from her former employer. But daily life is uncomfortable. She says it’s difficult to follow the diet she requires because she doesn’t have the resources.
“No one wants this and you don’t think it’s going to happen to you. You can’t work like this,” she says while she sits in her bed with a catheter in her abdomen.
There are seven other people in this room. They all have anxious faces because they are tired or because they are thinking about how to solve this situation.
“The intermittent unit, which has eight beds and should be used to handle eight patients, currently handles up 20,” says doctor Espinosa, explaining that they must take turns in order to attend them all, but that’s not a guarantee of optimum care.
And this is repeated in the other two units of dialysis, Health Care Center of Cañas and La Anexión Hospital in Nicoya, where 36 and 26 people respectively are attended.
Of the three units in the province, the one of Liberia is the one that cares for most Guanacastecans with this sticking point: 115 in total. It was the first unit opened, in 2006, and is the one that the Costa Rica Social Security Institute (CCSS, for its Spanish acronyms) will renovate in 2019 with the construction of a building to care for these patients. It will cost $2.8 million.
The new building will increase the number of beds for intermittent patients to 21, will have eight beds for patients that come in for appointments and will have kidney dialysis service with six beds.
Right now, those who require hemodialysis have to go all the way to the Hospital Mexico in San Jose. Some leave home at dawn and return at night.
“In terms of quality of life, for the patients in our region it’s really exhausting, because kidney dialysis is an invasive and rough treatment. The patient is exhausted, they distance themselves from family, they eat hospital food and, in general, are more institutionalized,” says doctor Espinosa.
The professionals that attend these patients hope that they open a new position for a nephrologist because there has only been one specialist in the region since 2015 and who only attends patients from the medical centers of Liberia and Cañas. Patients from Nicoya must go to Hospital Mexico in San Jose.
Guanacaste is the province with highest number of hospitalizations for this disease at a rate of 112.9 per 100,000 residents, according to data from the CCSS.
Oversaturation and a reduced number of professionals are common threads at the three units in the province. This overpopulation leads to limited care.
“Here, having the patient three days on dialysis - in intermittent treatment - we end up losing what we gain because they aren’t in dialysis Friday, Saturday or Sunday nor on holidays,” explains nurse Pilar Montiel from the La Anexión hospital, which sees patients from the cantons of Santa Cruz, Nicoya, Nandayure and Hojancha.
Eight people work in the Liberia unit: a general medicine doctor, a family doctor, five nurses and the only nephrologist in the region. This medical team on a daily basis sees intermittent patients and ambulatory patients who have an appointment once a month. This is in addition to the new and unexpected patients that are admitted each week.
On top of that, every Monday and Tuesday they visit the ambulatory patients to evaluate the conditions that they are living in.
“When we had 40 patients we could go every two months. Now that there are more than 100, six months could go by without us visiting them,” laments doctor Espinosa.
The kidney dialysis service won’t be expanded until next year when construction is started on the new unit of the Enrique Baltodano Hospital. Once completed, they will be able to better tend to a greater number of patients. Meanwhile, only hope eases their day to day lives.
Procedures and Inconveniences
Those who suffer from CKD have kidneys that have stopped functioning. That’s why all those who have had dialysis are waiting for a kidney donation.
Dialysis consists of a treatment that substitutes the functions of the kidney and allows the body to eliminate waste in the blood and the excess of liquid in the body. The two types of dialysis are peritoneal dialysis and hemodialysis.
In the first type a catheter is placed in the abdomen that allows fluids to enter and leave through a peritoneal membrane of the abdomen. In hemodialysis, this is done through access to arteries and veins.
In the unit at Enrique Baltodano, each patient has a metal stand next to their beds where the bags of fluid hang, a trash can full of towels, a bottle of spray with alcohol and a red notebook.
The process here and in homes is the same: every few hours (depending on what each patient is prescribed) they have to wash their hands and forearms for a few minutes, take a bunch of towels, walk to their bed, and spray the bags that contain the liquid and the stands that hold them with alcohol.
Then, with the towels, they dry everything and throw them away. They hang the bag on the stand and connect the catheter to the fluids.
“We have had people that don’t even know how to read or write, and the nurse is an education artist,” says doctor Espinosa, who hurriedly tries to resolve the health and infrastructure problems of her patients. “You have to teach them how to count from zero to 20 so they can balance their record book, the little red one.”