….........
1/28/15:
“My feet hurt. They burn.”
“How long?”
“6 months. Maybe more.”
“Do you have diabetes?”
“Si.”
“What do you take for your diabetes?”
“Metformin. Insulin.”
“How do you know how much insulin to take?”
“40.”
“Do you check your sugar?”
“How do I do that?”
OK, there wasn't much point to going there.
“How much Metformin do you take?”
“1 gram.”
“When did you last take it.”
“A long time. I can't buy it.”
Blood sugar was 441.
This was not a problem I was going to solve here.
Then I changed my thought.
Informed by another patient from another time, my question became:
What can I do with what I have.
We have Metformin. Just about a bucket full.
A trip to our dispensing pharmacy yielded a bag of Metformin.
He was so thrilled, he proclaimed at the gate to anyone who would listen:
“Look! I couldn't afford 30 days of Metformin. They gave me 6 months!”
I don't know that we made a real difference as measured by US standards, but, to him, someone cared.
And that's why we're here.
…......................
Once there was a boy.
All good stories start with “Once there was...”
Once there was a boy.
He was walking along the seashore, occasionally bending over then standing, tossing something.
An older, wiser man came along.
“What are you doing?”
“I'm tossing the starfish back in. The tide left them here. They will die here on the beach. So I am throwing them back.”
“Don't you know? There are a million starfish just on these few miles of beach. You're not making any difference!”
The boy, heedless, bent over and tossed another starfish back in.
“Well, to that starfish, it did!”
And that's why we're here.
…............................
I'll break habit for a few minutes.
The stories of patients we are seeing here are made possible by a self-organizing army.
That army is made of nurses.
Admittedly, it is trite and redundant to praise nurses.
Ever see a protest in favor of nuclear war?
The nurses have been manning the access point, the triage area.
There are some 300 “tickets” given per day.
Do the math.
If a physician sees every one of these and we have 4 physicians, at 15 minutes each we'd be done with the first day sometime next week.
So, with physician backing (not that it's needed, but it's good to have everyone on board communicating), the nurses have organized the intake process.
The basic concept is thus: If, in their collective experience, what the patient needs is something they could do without a physician or can be handled by protocol order (antihelmenthic for weight), they just do it.
The idea is to drive decision making to the level closest to the decision.
This is a deceptively simple concept.
Command-and-control systems have never worked; this one does.
And it is due to people taking responsibility for their professional actions and executing the mission.
And how successful?
Over ½ of the people presenting for care are cared for primarily and only by the nurses.
The physicians make periodic visits to maintain appearances.
But frankly, given the acceptance of the populace and the excellence of the nurses' work, I think it's just vanity.
Which is ok; we have a lot to be vain about!
…................
72 years old.
She had this ache.
That ache.
Legs hurt.
Bowels were slow. Or fast.
Headache.
In the US, fibromyalgia; a group ripe to get hooked on narcotics.
And narcotizing pain might be ok as long as one can live with the consequences.
But she didn't want narcs and I didn't have any.
So we talked.
She lived at home; no nursing home or assisted living.
How long ago had her mother died?
She didn't; she's 85!
As we talked more, the patient disclosed she was afraid of dying.
And this lead to a conversation in English-Spanish with a translator helping.
We talked about how none of us will get out of this life alive.
We talked about her life to now.
We talked of many things.
But mainly we talked of living.
And, on leaving, she gave us both a hug.
She said she felt better.
And I felt I'd been paid a fortune.
…..................
Weak.
Fever.
Short of breath.
Oxygen at 92%.
Heart too fast.
Crackles in the right lower lobe.
She had pneumonia.
I didn't need an Xray for that diagnosis.
I did need guidance.
We got her Tylenol.
A breathing treatment.
Oral antibiotics.
We talked to the patient and family about what to do next.
They were clear: antibiotics and take care of the matriarch at home.
With an admonition to goto the hospital if she worsened, we got a week of levofloxacin ready for her.
But how to get her from the clinic to the auto?
We didn't have a wheelchair and there were stairs to mount.
Up show the Bomberos, local Fire Brigade.
They made a Bomberos-chair.
A plastic resin deck chair and a few strong men, a trip up roads and trails and she is at home.
The outcome?
I don't know.
…..................................
Weak, tired, headache.
I'd heard it all before.
But not from her.
For each patient, you begin anew.
Their telling of their story to you is anew.
Muscles ache.
“Where do you work?”
“At home.”
“How many children?”
“Quattro.”
They were all in the room with us.
“Is there anyone else at home to help?”
“My husband is dead.”
She was young, just 25.
“I'm sorry to hear that; he must have been young. What happened?”
“Motor vehicle crash.”
Widowed. Young. 4 children.
Her pain was so much more than physical.
All I had to offer was a sympathetic ear.
And with the superb aid of an interpreter, we heard her story.
Sometimes all you can to is listen, witness.
And sometimes, that is enough.
…..................
“Las piernas duelan.”
My legs. They hurt.
She was on the far side of 70.
I am sure she had done her fair share of hard work.
Her legs hurt, she tells me, when she has to walk a long way.
How far? When?
Today. A half hour.
She had surprisingly good pulses; blood vessel blockage unlikely, especially with a ½ hour walk!
The varicosities on her legs told another story, long hours on her feet.
Caring for a family?
Working to make tacos, frijoles,sustenance for a family?
I couldn't change her life.
But with an elastic bandage for each leg, I could make her feel better.
And she walked out with a lighter step.
…..........................................
She was slight of build.
Her answers were swift, certain.
In summary, she just wanted to know she was alright.
She was.
So we talked.
“What are you going to do with yourself?”
“Go to university.”
“To study what?”
“Teaching.”
“What do you want to teach?”
“Math.”
“At what grade level?”
“High school.”
Great goal. And I thought she could do it.
“My daughter teaches in high school.”
“How does she like it?” she asked.
“Loves it and the students love her. When she complained about being short, her students corrected her: 'Miss, you're not short, you're fun-sized.'”
She laughed and got up.
And I made the only useful suggestion I could think of:
“No chicitos (boys).”
She laughed again.
I think she'll make it.
…..............................
An aside that is far from an aside.
With my skills at Spanish, i'd be sunk without help.
We have translators, interpreters.
What a privilege, to hear these stories.
They help immeasurably.
Of course, there's the nuts and bolts of ensuring I understand what the patient is saying and vice versa.
But there is much more.
I'll leave out names; those here will recognize these people.
I'll add names only if given permission of the names' owners.
First is the lead translator; she met us at the airport and kept up a lively string of commentary all the way to our Base of Operations. (See Lat/long at the beginning.)
She volunteers her young daughter to help.
Although a bit embarrassed at some of the questions, she helps, especially in the Respiratory section.
There's a woman who works with street people. She helps me understand why people who are homeless return to the streets from a shelter. The streets are home. From her, I get an education on this population that I can apply back home.
And she studies me quickly. She learns my routine instructions so well that I can give the first sentence and she runs with the rest. She's like a macro; I'll work with her any day,
Then there's a familiar tone speaking unfamiliarly. That is clearly an Italian-accented Spanish speaking English flawlessly. (Aside: I love listening to languages and Italian is, to my ear, one of the most beautiful. In Spanish, it's even better.) We work together at the end of a long day. She is clearly tired; I am. But she gamely lies and accepts another patient.
Last and hardly least is a priest who accompanies us.
(OK, who this is is hardly confidential.)
His Spanish is smooth, practiced. And you can tell he's worked with people; my most intimate, embarrassing questions are translated both ways without a hint of judgment. Clearly, the people trust him. As do I.
We clinicians trust these people to help us make the best medical judgment we can for this population in the circumstances we all find ourselves.
And isn't that what it's all about?
…............
The stories.
What a dream job.
I get to hear stories.
People tell me stories all day long.
What a dream job.
All I have to do is listen
…...........................
1/29/15:
Yours from Honduras;
Us
