Diary from a Week in Practice
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Am Fam Physician. 2003 Jun 1;67(11):2312-2314.
This week, JOH, along with two other physicians and a pediatric nurse practitioner, traveled to Palenque, Mexico, to provide medical care to the people of that area. The trip was sponsored by the Franciscan Sisters of Stella Niagara, who have a convent in Palenque. The first day was spent at a rural ejido (small community) two hours from the city. The team saw 260 patients, many of whom spoke only Chol, a native language of that area. The Sisters translated from Chol to Spanish. An intensive Spanish course taken before the trip provided a basic knowledge of medical terms. But, nothing could prepare JOH for the poverty of the region. Single-room dwellings of wood and tin provided shelter for many family members. The clinic was a sturdier gathering place for the community. Bedspread partitions separated the consultorios (offices). Many of the complaints of the patients resulted from the hard work that they did day-in and day-out—backaches, headaches, stomach pain, and leg pain. When the last patient was seen, the team was invited to the home of the jefe (chief) for a meal of eggs, vegetables, and tortillas. The two-hour ride back to Palenque was quiet, while the team tried to assimilate what they had witnessed. Could any place have been farther from the world from which they came?
Today, the destination of the team was only an hour from Palenque. A church served as the clinic building, and dirt floors and a pile of sand in the back of the structure attested to its unfinished state. The wooden pews had been turned to face each other to provide a consultorio, and the cloth partitions brought from the convent provided some semblance of privacy. The people lined up in the hot sun awaiting their turns. Two minor surgeries were done under less than sterile conditions—an excision of an inclusion cyst on a leg and the removal of a ganglion cyst on a foot, both of which had been present for years. The saddest patient of the day was a young girl who stuttered badly and began crying while presenting her physical complaints to JOH. Whether the tears were because of unease from her speech problem or because of her pain was unclear. JOH felt that it was the former and tried to comfort her with advice to correct the stuttering. Her parents listened intently and manifested their love and concern for their beautiful daughter. Again, after the last patient had been seen, a feast of fresh orange juice, chicken, frijoles, and tortillas was provided to the team. The routine was now more familiar, and the fatigue at the end of the day was not quite as profound as the day before.
JOH rose early, had breakfast with the Sisters, and loaded the pickup truck with medicines and supplies. He used a pillowcase to carry his stethoscope, otoscope, blood pressure cuff, and pulse oximeter. The latter was rarely used because shortness of breath was a rare complaint. The ejido, an hour's ride from Palenque, was called Betania and was home to one of the Sisters. The clinic was set up in a public building with good ventilation. Chol and Tseltal were the languages spoken and when there was difficulty with the translation from Spanish, the one Sister who spoke English interpreted. Lumbrices (worms), parasitos (parasites), and animalitos (little animals) were words that came up frequently. Fortunately, the supply of antiparasiticals was sufficient, and instructions on purifying the drinking water were reinforced regularly. At the end of the day, the team was invited to a meal of chicken broth, tortillas, and water in the house of the town deacon. The single room was home to the parents, seven children, and pigs and chickens. Their generosity and smiles attested to the truth that happiness is not dependent on possessions. On the return to Palenque, a stop for a refreshing swim in the river removed most of the dust acquired on the journey. Sleep came quickly this night.
After a breakfast of pan dulce (sweet bread), fried bananas, and fresh orange juice, the pickup truck was loaded with medical supplies and we left for another village. After almost a week of immersion in Spanish, JOH was beginning to feel more comfortable conversing with patients. The day-to-day interchange of non-medical conversation was quite another story. This clinic was two hours from Palenque in a small church. The patients were waiting as the team unloaded the supplies and set up the consultorios. One of the patients seen by KL, a third-year resident in physical medicine and rehabilitation, presented with a 6-cm sebaceous cyst on her left cheek, which she was hoping to have removed. The surgery took place on the church pew under local anesthesia, and the patient was very happy to have the unsightly mass removed. The rest of the patients were treated for primarily medical problems, and while the supply of medications was running low after a week, the stockpile, which had come by truck from Buffalo, New York, three months earlier, held up remarkably well. After another homemade meal at the end of the day, the team packed up and returned to Palenque.
Time is about the only commodity most residents of this area of Mexico have in abundance. Today, the clinic was located at the convent and began at 8 a.m., although the patients began waiting in the courtyard some time before. As the team had breakfast, Doña L, a native of Palenque who volunteered at all of the clinics, took the names of those wishing to be seen. One older woman had a massive abdominal wall hernia and had been told by a local physician that surgery would be required. Having no funds for this, she came to the clinic in the hope of getting some relief. Her high blood pressure had not been addressed previously but was more emergent than the hernia and could be treated medically. She would have follow-up from Sister M, who had trained as a nurse and who would be able to visit the ejidos throughout the rest of the year after the doctors left. The last patient was seen by the early afternoon. As the team drove back to its lodgings at the end of the day, ZP, a veteran of the Palenque mission, was bemoaning the fact that he had not yet seen any tarantulas. His wish was granted when JOH arrived upstairs in the sleeping quarters—two of the hairy arachnids were lying in wait, but they were not fast enough to escape their rapid expulsion by stick to the outside of the house.
Another day of clinic in Palenque. The stream of patients began before 8 a.m. Because headache and backache were the most prevalent complaints, the supply of nonsteroidal anti-inflammatory medications was ebbing. Tseltal was spoken by most of the patients today, and the Sisters translated for the team. A young man presented with a four-week history of a generalized pruritic rash that appeared to be spreading. There was no rash on his wife or children, which made scabies less likely. Like many dermatoses, the erythematous, papulovesicular small discrete lesions were not pathognomonic, and JOH resorted to prednisone, an antihistamine, and steroid cream as therapy. Another patient, an elderly woman, had developed presbyopia and was unable to continue her sewing trade. [corrected] Sister B heard of her plight and foraged in the box filled with donated spectacles. When the right pair was found, the woman was able to thread a needle again. Her smile flowed from the realization that she could now resume her work and was a beautiful reward for the mission team this day. The next day would see them depart for the United States. JOH realized that life would never be quite the same for any of the team members. They would return to their homes with life-altering memories.
After years spent in private family practice and academia, John O'Handley, M.D., is medical director of the Mount Carmel Outreach Program in Columbus, Ohio. The program provides free medical care to uninsured and homeless patients throughout the city on a mobile coach clinic. Dr. O'Handley continues to see private patients two mornings a week.
Address correspondence to John O'Handley, M.D., 1335 Dublin Rd., Suite 110E, Columbus, OH 43215 (e-mail: firstname.lastname@example.org).
In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.
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